High Prescribing and State-Level Variation in Z-Drug Use Among Medicare Patients

Anderson, Kaitlin E.; Gifeisman, Rachel I.; Basting, James L.; Harris, Donovan J.; Rajan, Antonica R.; McCall, Kenneth L.; Piper, Brian J.

doi:10.1055/a-2085-2299

Cited by 4 publications

(3 citation statements)

References 17 publications

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“…The number of providers per specialty was obtained from Medicare Physician and Other Practitioners by Specialty and Service ( 36 ). Medicare Specialty Utilization and Payment Data has been used in other pharmacoepidemiology reports ( 34 , 37 , 38 ).…”

Section: Methodsmentioning

confidence: 99%

“…Specialties for whom taxonomy codes could not be mapped to a Medicare specialty code were excluded. The methods employed in this investigation have been used to assess chronologic, geographic, and specialty prescribing patterns of other medications among Medicare patients ( 34 , 37 , 38 ). Data was analyzed using Excel and figures were constructed using GraphPad Prism and Heatmapper ( 42 ).…”

Section: Methodsmentioning

confidence: 99%

“…A recent investigation demonstrated concerningly high use of the nonbenzodiazepine hypnotics, a class of psychiatric medications considered as PIMs by the AGS among Medicare patients ( 34 ). Further, it was noted that such prescription patterns displayed significant variation among states and specialties ( 34 ). However, no study to date has examined such prescribing patterns of paroxetine in this population.…”

Section: Introductionmentioning

confidence: 99%

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National patterns of paroxetine use among US Medicare patients from 2015–2020

Cavanah,

Goldhirsh,

Huey

et al. 2024

Front. Psychiatry

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IntroductionParoxetine is an older “selective” serotonin reuptake inhibitor (SSRI) that is notable for its lack of selectivity, resulting in an anticholinergic adverse-effect profile, especially among older adults (65+).MethodsParoxetine prescription rates and costs per state were ascertained from the Medicare Specialty Utilization and Payment Data. States’ annual prescription rate, corrected per thousand Part D enrollees, outside a 95% confidence interval were considered significantly different from the average.ResultsNationally, there was a steady decrease in population-corrected paroxetine prescriptions (-34.52%) and spending (-29.55%) from 2015–2020 but a consistent, five-fold state-level difference. From 2015–2020, Kentucky (194.9, 195.3, 182.7, 165.1, 143.3, 132.5) showed significantly higher prescriptions rates relative to the national average, and Hawaii (42.1, 37.9, 34.3, 31.7, 27.7, 26.6) showed significantly lower prescription rates. North Dakota was often a frequently elevated prescriber of paroxetine (2016: 170.7, 2018: 143.3), relative to the average. Neuropsychiatry and geriatric medicine frequently prescribed the most paroxetine, relative to the number of providers in that specialty, from 2015–2020.DiscussionDespite the American Geriatrics Society’s prohibition against paroxetine use in older adults and many effective treatment alternatives, paroxetine was still commonly used in the US in this population, especially in Kentucky and North Dakota and by neuropsychiatry and geriatric medicine. These findings provide information on the specialty types and states where education and policy reform would likely have the greatest impact on improving adherence to the paroxetine prescription recommendations.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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National patterns of paroxetine use among US Medicare patients from 2015–2020

Cavanah,

Goldhirsh,

Huey

et al. 2024

Front. Psychiatry

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Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep

Gardner,

Turner,

Magalhaes

et al. 2024

JAMA Psychiatry

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ImportanceDirect-to-patient interventions enabling transitions from long-term benzodiazepine receptor agonist (BZRA) use to cognitive behavioral therapy for insomnia (CBTI) by older adults has the potential to reduce BZRA use and related harms while improving sleep outcomes without requiring prearranged clinician involvement.ObjectiveTo compare 2 direct-to-patient behavior change interventions with treatment as usual (TAU) on BZRA use, sleep, and other health outcomes, and uptake of CBTI techniques.Design, Setting, and ParticipantsThe Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study was a 3-arm, pragmatic, open-label, minimum-contact, randomized clinical trial. The study began November 2020 and ended June 2022. Participants were randomly allocated to 1 of 3 groups, including 2 different mailed behavior change interventions or no intervention (TAU). Participants were from communities across the province of New Brunswick, Canada, and included adults 65 years and older living independently with long-term use of BZRAs and current or past insomnia.InterventionsThe Sleepwell package (YAWNS-1) consisted of a cover letter and 2 booklets (“How to Stop Sleeping Pills” and “How to Get Your Sleep Back”). The other package (YAWNS-2) included updated versions of the 2 booklets (“You May Be at Risk” and “How to Get a Good Night’s Sleep Without Medication”) used in the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) study.Main Outcomes and MeasuresBZRA use at 6 months was the primary measure. Secondary measures included CBTI use, sleep, insomnia, daytime sleepiness, safety, anxiety, frailty, and quality of life.ResultsA total of 1295 individuals expressed interest in the study, and 565 (43.6%) completed a baseline assessment. Participants had a mean (SD) age of 72.1 (5.7) years, a mean (SD) BZRA use duration of 11.4 (9.1) years, and 362 (64.1%) were female. Discontinuations and dose reductions of 25% or greater were highest with YAWNS-1 (50 of 191 [26.2%]; 39 of 191 [20.4%]; total, 46.6%) compared with YAWNS-2 (38 of 187 [20.3%]; 27 of 187 [14.4%]; total, 34.8%, P = .02) and TAU (14 of 187 [7.5%]; 24 of 187 [12.8%]; total, 20.3%, P &lt; .001). YAWNS-1 also demonstrated better uptake of CBTI techniques and sleep outcomes compared with YAWNS-2 (new CBTI techniques: 3.1 vs 2.4; P =.03; sleep efficiency change: 4.1% vs −1.7%; P =.001) and reduced insomnia severity and daytime sleepiness compared with TAU (insomnia severity index change: −2.0 vs 0.3; P &lt;.001; Epworth Sleepiness Scale change: −0.8 vs 0.3; P =.001).Conclusions and RelevanceResults of the YAWNS NB randomized clinical trial show that, as a simple, scalable, direct-to-patient intervention, YAWNS-1 substantially reduced BZRA use and improved sleep outcomes. It could be implemented to transform insomnia care for older adults at the population level.Trial RegistrationClinicalTrials.gov Identifier: NCT04406103

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Insomnia in ambulatory care: A clinical review

Dopheide,

Roth,

Chu

2024

American Journal of Health-System Pharmacy

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Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose One-third to one-half of ambulatory care patients report insomnia. The objective of this clinical review is to detail the many causes and evidence-based treatment options for insomnia in outpatients and to recommend screening and summarize evidence for the place in therapy of prescription and nonprescription treatments. Summary This work provides an overview of the literature on insomnia regarding causes, patient assessment, and nonpharmacological and pharmacological treatments. Patients who present with insomnia should be assessed for sleep apnea, restless legs syndrome, narcolepsy, and all contributing medications as well as medical, psychiatric, and substance use disorder diagnoses. The type of insomnia, namely difficulty falling asleep, difficulty maintaining sleep, and early morning awakening with resulting functional impairment, should be documented in addition to whether insomnia is short term or persistent. Cognitive behavioral therapy for insomnia (CBT-I) or digital CBT-I is first-line treatment for all patients with insomnia irrespective of the cause or type. Nonprescription treatments such as antihistamines or melatonin are for select populations. Prescription hypnotics are best utilized on an as-needed basis or for nightly use for less than 6 weeks. Z-hypnotics are safe and effective for insomnia in persons with depression or an anxiety disorder but should be avoided in older individuals or if there is respiratory or cognitive impairment. Orexin receptor antagonists are effective for sleep initiation and maintenance in healthy persons or if there is mild cognitive impairment, but they require further study in individuals with psychiatric and medical diagnoses. Trazodone is the most prescribed off-label treatment due to its efficacy for sleep initiation and maintenance and its lack of abuse potential. Conclusion Insomnia treatment should be guided by patient age, diagnoses, and type of insomnia. Pharmacological treatments should be used at the lowest effective dose for the shortest duration of time.

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High Prescribing and State-Level Variation in Z-Drug Use Among Medicare Patients

Cited by 4 publications

References 17 publications

National patterns of paroxetine use among US Medicare patients from 2015–2020

National patterns of paroxetine use among US Medicare patients from 2015–2020

Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep

Insomnia in ambulatory care: A clinical review

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