Linking a Survey of Clinician Benzodiazepine-Related Beliefs to Risk of Benzodiazepine Prescription Fills Among Patients in Medicare

Donovan T. Maust; Lewei (Allison) Lin; Molly Candon; Julie Strominger; Steven C. Marcus

doi:10.1370/afm.2883

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Table 1.

Characteristics of Sample of Primary Care Clinicians Prescribing BZDs

Characteristic	Overall (n = 100)	Responded (n = 61)	Did not Respond (n = 39)	P Value^{^a}
Male, No. (%)	61 (61.0)	36 (59.0)	25 (64.1)	.61
Age, y, mean (SD)	56.8 (12.6)	56.5 (10.4)	57.4 (15.6)	.76
Physician specialty, No. (%)
Family medicine	51 (51.0)	36 (59.0)	15 (38.5)	.04
Internal medicine	48 (48.0)	24 (39.3)	24 (61.5)
Geriatric medicine	1 (1.0)	1 (1.6)	0
Percentage of patients prescribed a BZD, mean (SD)^{^b}	12.1 (6.3)	11.5 (5.9)	13.0 (7.0)	.62
Benzodiazepine prescribed^{^c}
Lorazepam	89 (89.0)	55 (90.2)	34 (87.2)	NA
Alprazolam	80 (80.0)	51 (83.6)	29 (74.4)
Clonazepam	67 (67.0)	40 (65.6)	27 (69.2)
Diazepam	49 (49.0)	31 (50.8)	18 (46.2)
Temazepam	44 (44.0)	25 (41.0)	19 (48.7)
Clorazepate	5 (5.0)	3 (4.9)	2 (5.1)
Clobazam	3 (3.0)	0	3 (7.7)
Triazolam	3 (3.0)	3 (4.9)	0
Oxazepam	2 (2.0)	1 (1.6)	1 (2.6)
Flurazepam	1 (1.0)	1 (1.6)	0

BZD = benzodiazepine; NA = not applicable.
↵a Respondents were compared with nonrespondents using a χ² test for gender and physician specialty and a t test corrected for unequal variance for age. For physician specialty, the χ² test was conducted after removing 1 physician given the small sample size for geriatric medicine (n = 1).
↵b For percentage of patients prescribed a BZD, patient-level data and modified Poisson with robust SE values were used to examine if there was a relation between response status (0/1) and risk of being prescribed a BZD.
↵c Column percentages might sum to >100% because a given clinician can prescribe >1 BZD.

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Table 2.

Associations Between Primary Care Clinician Beliefs Related to BZD Prescribing and Patient-Level Risk of Being Prescribed a BZD

Survey Item	Clinicians, No. (%) (n = 61)	Patients, No. (%) (n = 5,385)^{^a}	Patients Filling BZD, No. (%)^{^b}	Adjusted RR (95% CI)^{^c}
The following statements were introduced by, “To what extent do you agree with the following statement about benzodiazepine treatment?”
If a patient has been prescribed a benzodiazepine for years, the potential harms from continuing the benzodiazepine are low.
Strongly disagree/disagree	38 (62.3)	3,352 (62.2)	403 (12.0)	1.0 (reference)
Neither	12 (19.7)	908 (16.9)	75 (8.3)	0.67 (0.47-0.94)^{^d}
Agree/strongly agree	11 (18.0)	1,125 (20.9)	167 (14.8)	1.31 (1.01-1.7)^{^d}
If a patient has been prescribed a benzodiazepine for years, a taper would be an unnecessary source of distress.
Strongly disagree/disagree	52 (85.2)	4,750 (88.2)	588 (12.4)	1.0 (reference)
Neither	7 (11.5)	483 (9.0)	37 (7.7)	0.7 (0.36-1.36)
Agree/strongly agree	2 (3.3)	152 (2.8)	20 (13.2)	1.09 (0.75-1.6)
Patients are usually unwilling to be tapered off benzodiazepines.
Strongly disagree/disagree	9 (14.8)	991 (18.4)	144 (14.5)	1.0 (reference)
Neither	13 (21.3)	1,299 (24.1)	156 (12.0)	0.82 (0.58-1.15)
Agree/strongly agree	39 (63.9)	3,095 (57.5)	345 (11.1)	0.73 (0.5-1.04)
For anxiety, benzodiazepines work better than other treatments.
Strongly disagree/disagree	33 (54.1)	3,042 (56.5)	372 (12.2)	1.0 (reference)
Neither	21 (34.4)	1,750 (32.5)	214 (12.2)	1.03 (0.79-1.33)
Agree/strongly agree	7 (11.5)	593 (11.0)	59 (9.9)	0.82 (0.48-1.4)
For insomnia, benzodiazepines work better than other treatments.
Strongly disagree/disagree	43 (70.5)	3,700 (68.7)	444 (12.0)	1.0 (reference)
Neither	12 (19.7)	1,055 (19.6)	129 (12.2)	1.04 (0.79-1.37)
Agree/strongly agree	4 (6.6)	415 (7.7)	50 (12.0)	0.99 (0.6-1.62)
No response	2 (3.3)	215 (4.0)	22 (10.2)	NA
Tapering a benzodiazepine would involve more frequent patient visits.
Strongly disagree/disagree	9 (14.8)	789 (14.7)	86 (10.9)	1.0 (reference)
Neither	10 (16.4)	1,086 (20.2)	159 (14.6)	1.38 (0.87-2.18)
Agree/strongly agree	42 (68.9)	3,510 (65.2)	400 (11.4)	1.0 (0.65-1.54)
In the past year, among all your patients who take benzodiazepines regularly (either scheduled or PRN), with what percentage of patients did you discuss decreasing or discontinuing the benzodiazepine?
0%	0	NA	NA	NA
1% to 25%	7 (11.5)	597 (11.1)	76 (12.7)	1.0 (reference)
26% to 50%	16 (26.2)	1,463 (27.2)	185 (12.6)	0.98 (0.67-1.43)
51% to 75%	16 (26.2)	1,254 (23.3)	148 (11.8)	0.96 (0.64-1.43)
76% to 100%	21 (34.4)	1,981 (36.8)	232 (11.7)	0.89 (0.61-1.32)
No response	1 (1.6)	90 (1.7)	4 (4.4)	NA

BZD = benzodiazepine; NA = not applicable; PRN = pro re nata (as needed); RR = relative risk.
↵a These 5,385 patients were all Medicare beneficiaries who filled a Part D prescription in 2017 written by the 61 clinician survey respondents.
↵b Among patients of clinicians with a given response level (eg, among 3,352 patients whose clinicians disagreed or strongly disagreed with the statement, “If a patient has been prescribed a benzodiazepine for years, the potential harms from continuing the benzodiazepine are low,” 403 [12.0%] filled a BZD prescribed by those clinicians).
↵c From a modified Poisson regression model with robust SE values. Adjusted for patient age, gender, and Part D low-income subsidy.
↵d P < .05