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. 2018 Dec;33(12):2180-2188.
doi: 10.1007/s11606-018-4670-9. Epub 2018 Sep 24.

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA

Donovan T Maust  1   2   3 , Lewei A Lin  4   5   6 , Frederic C Blow  4   5   6 , Steven C Marcus  7
Affiliations

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA

Donovan T Maust et al. J Gen Intern Med. 2018 Dec.

Abstract

Background: Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms.

Objective: To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries.

Design: Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF).

Subjects: n = 122,054 PCPs who prescribed 37.3 billion medication days.

Main measures: 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.

Key results: 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.

Conclusions: 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.

Keywords: anxiety; benzodiazepine; insomnia; physician; primary care.

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Conflict of interest statement

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.

Figures

Figure 1
Figure 1
County-level benzodiazepine prescribing intensity by primary care physicians across 50 states and the District of Columbia (n = 3038). The red horizontal line is the national county-level mean (2.1%); the dashed blue lines reflect the 25th and 75th percentiles (1.5 and 2.6%, respectively).
Figure 2
Figure 2
County-level Intensity of benzodiazepine prescribing by primary care physicians (n = 3038).
See this image and copyright information in PMC

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