Title: Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies.

Background: Before 2014, there was no record of medications billed under the Medicare hospice benefit. After opioids, benzodiazepines (60%) and antipsychotics (38%) are most often prescribed to Medicare hospice patients. These medications are commonly used in hospices to manage symptoms like terminal restlessness, agitation, and intractable nausea. There is limited high quality data to guide use. Little is known about prescribing factors.

Design and Participants: Retrospective cohort study of 20% sample of Medicare patients (>65yo) newly enrolled in hospice. Participants are Medicare patients from 2014-2016 without benzodiazepine or antipsychotics prescribed prior to enrollment in hospice.

Results: Demographic-wise, more cancer patients, younger patients (65-74), and slightly more male patients were prescribed benzodiazepines and antipsychotics. More non-Hispanic Whites than Blacks received benzos, but these groups equally received antipsychotic prescriptions. For-profit and large hospice agencies were more likely to prescribe both types of meds. Agency prescribing rates had the largest adjusted hazard ratio for prescribing (Benzos 10.7x, Antipsychotic 51.7x). When the authors accounted for small prescription fills in early enrollment (comfort kits) and in the three days prior to death, the study finding did not change.

Commentary: I selected this article to better understand variations in comfort kit prescribing (KP and other local hospice med choices). Ultimately, I got something different (but Amos’ cohort study on hospice kit impact is listed below¹). Hospice agency factors are stronger driver of benzo and antipsychotic prescribing than patient characteristics. Frankly, I’m more interested in the prescribing findings comparing 2019-2022 to 2014-2016. There are few RCT guiding end of life management of distressing symptoms (placebo and benzo > haloperidol and risperdone^2,3). Most of those that are cited in this article, to question prescribing, are published in or after 2017. Maybe the recent data would be affected by the impact of those studies rather than data collected from 2014-2016. Study findings of nursing home antipsychotic prescribing, the commentary from the New Yorker article about for-profit hospices⁴, all make me more suspicious of the for-profit agencies’ high prescribing findings. However, the authors rightly recommend further study here. Certainly, the study is limited by analysis of prescription fills, not actual administration, or indication for prescribing. Because it’s a higher-level data set, we don’t know details of provider-level factors, use of non-pharm care strategies or variables of caregiver burden.

Bottom Line: High incidence of benzodiazepine and antipsychotic prescribing connected to hospice agency factors need further investigation into details of prescribing cultures across agencies.

References:

1. Bailey FA, Williams BR, Goode PS, et al. Impact of a hospice emergency kit for veterans and their caregivers: a prospective cohort study. J Palliat Med. 2014;17(8):931-938. doi:10.1089/jpm.2013.0395
2. Hui D, Frisbee-Hume S, Wilson A, et al. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial.JAMA. 2017;318(11):1047-1056. doi:10.1001/jama.2017.11468
3. Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial [published correction appears in JAMA Intern Med. 2017 Feb 1;177(2):293].JAMA Intern Med. 2017;177(1):34-42. doi:10.1001/jamainternmed.2016.7491
4. https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle

Source:  Gerlach LB, Zhang L, Strominger J, et al. Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies. J Gen Intern Med. 2022;37(15):3814-3822. doi:10.1007/s11606-022-07604-3