County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA
Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms.
To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries.
Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF).
n = 122,054 PCPs who prescribed 37.3 billion medication days.
Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing.
Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73–0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91–0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90–4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing.
BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.
KEY WORDSbenzodiazepine insomnia anxiety physician primary care
Only those acknowledged as authors.
This work was supported by the Beeson Career Development Award Program (NIA K08AG048321, the American Federation for Aging Research, The John A. Hartford Foundation, and The Atlantic Philanthropies) and NIDA 1R01DA045705.
Compliance with Ethical Standards
Conflict of Interest
Dr. Marcus reports receiving consulting fees from Alkermes, Allergan, Sage Therapeutics, Sunovion Pharmaceuticals, and Ortho-McNeil Janssen. All remaining authors declare that they do not have a conflict of interest.
- 8.Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403–39.CrossRefGoogle Scholar
- 25.Centers for Medicare & Medicaid Services. medicare fee-for-service provider utilization & payment data part d prescriber public use file: a methodological overview. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Prescriber_Methods.pdf. Accessed July 24, 2018.
- 26.Center for Medicare & Medicaid Services. Part D Drug National Summary table, CY2015. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/PartD2015.html. Accessed July 24, 2018.
- 27.U.S. Department of Housing and Urban Development. HUD USPS Zip Code Crosswalk Files. https://www.huduser.gov/portal/datasets/usps_crosswalk.html#codebook. Accessed July 24, 2018.
- 28.Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps. http://www.countyhealthrankings.org/. Accessed July 24, 2018.
- 29.Health Resources and Services Administration. Area Health Resources Files (AHRF): Overview. Rockville, MD. http://ahrf.hrsa.gov/overview.html. Accessed July 24, 2018.
- 30.Centers for Medicare & Medicaid Services. Physician Compare Datasets. https://data.medicare.gov/data/physician-compare. Accessed July 24, 2018.
- 34.Centers for Disease Control and Prevention. Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010. MMWR Morb Mortal Wkly Rep.. 2012;61(1):14.Google Scholar