• Lauren B Gerlach, Lan Zhang, Julie Strominger, Hyungjin Myra Kim, Joan Teno, BynumJulie P WJPWInstitute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA., and Donovan T Maust.
• Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA. glauren@umich.edu.
• J Gen Intern Med. 2022 Nov 1; 37 (15): 381438223814-3822.

BackgroundBenzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies.ObjectiveExamine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice.DesignRetrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice.ParticipantsMedicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment.Main MeasuresThe primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics.Key ResultsA total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing.ConclusionsThe pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

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