Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing

BACKGROUND: Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. METHODS: Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. RESULTS: 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. CONCLUSIONS: Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.