In 2017, the use of benzodiazepines and antipsychotic agents differed markedly among 1.4 million hospice-enrolled Medicare beneficiaries aged 65 years or older across factors other than clinical characteristics, researchers report. “Large differences [were] exhibited by non-clinical hospice agency characteristics including profit status, size, and region,” conclude the authors. “As with any medical treatment, the decision to prescribe a medication should be driven by a clinical need. However, we found a wide range of use across hospice agencies, with large and for-profit agencies accounting for a larger proportion of high-prescribing facilities, which suggests significant variation in what is considered clinically appropriate use in this population. Because of variation in prescribing across agency-level characteristics, such agency features may be important elements to help develop and focus interventions to promote appropriate prescribing. Finally, it will be critical to explore the extent to which individual clinicians may contribute to this variation.”
Based on a main outcome of the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles, the cross-sectional analysis showed the following: “In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic-prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6–0.7, Hispanic RR 0.4, 95% CI 0.3–0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6–0.8, Hispanic RR 0.4, 95% CI 0.3–0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2–1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5–2.7) and antipsychotics (RR 2.7, 95% CI 2.6–2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3–2.4; antipsychotic: RR 2.3, 95% CI 2.2–2.4). Prescribing rates varied widely across Census regions.”