Chester Clinic

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Utilization of Benzodiazepines and Barbiturates after Medicare Part D Coverage
Van Doren Hsu, Pharm.D., Jean O'Donnell, M.S. Figure 2. Barbiturate PDEs by Pharmacy Dispensing Type and Prescriber Specialty
Figure 5. Prevalence of Benzodiazepine by Drug
• Overall BARB and BZD PDE use and by • A total of 65.8% and 72.9% of Benzodiazepines (BZD) and barbiturates (BARB) were excluded from Age group (<65 vs. 65 and older) the BZD PDEs were short or Medicare Part D covered drugs from 2006 to 2012. Starting in 2013, the intermediate acting (SA/IA) Part D program began to cover BZD for all Part D medically accepted BZDs in all users and the subset Low income subsidy (LIS) status (based on positive low income cost sharing of users aged 65 years and older indications and BARB when used in the treatment of epilepsy, cancer or Neurology, 17.3% (older users), respectively. chronic health disorders. Primary pharmacy dispensing type (Retail, Long-Term Care (LTC), Other) • Alprazolam and clonazepam had Prescriber specialty The study objective was to examine the cost and use of these drugs in the highest percent of SA/IA and Prevalence of BARB and BZD Medicare beneficiaries since most of these drugs are included by Beers' LA BZD PDEs, respectively in Total prescription cost of BARB and BZD criteria1 as potentially inappropriate drugs in older adults. Primary Care, 58.9% users of all ages and those who were 65 years and older. • The mean ± SD number of PDE per BZD user was 5.7±5.2 Table 1. Utilization and Total Prescription Cost for BARB and BZD among 2013 PDEs
compared to 5.0±4.7 in older Pharmacy Dispensing Type Prescriber Specialty Data Source from Chronic Condition Warehouse (CCW)
• 2013 Prescription Drug Event (PDE) 2013 PDEs
Primary care includes Internal Medicine, Family Medicine and General Practitioner; NP/PA=Nurse • 2013 Beneficiary Summary Practitioner/Physician Assistant All ages
• 2013 Drug Characteristics Figure 6. Prevalence of Benzodiazepine among BZD Users
• 2013 Prescriber Characteristics Number of PDEs
39,506,319 (2.88%) • A total of 86.6% of all BZD users • 2013 Pharmacy Characteristics Number of LIS PDEs
17,917,600 (3.14%) Figure 3. Characteristics of Benzodiazepine PDEs
only had one unique drug vs. 88.9% of the older users. Study Population
Total prescription cost (million)
• The prevalence of only SA/IA Beneficiaries who had ≥1 PDE in 2013 were included in the denominator. Number of users
6,953,278 (19.80%) and LA BZD use was 64.0% and The numerator included those with one or more BARB or BZD PDEs. 27.9%, respectively while 8.1% used both types of BZD. Aged 65 or older
≥65 years old, Ascertainment of BARB or BZD
Number of PDEs
24,365,608 (2.32%) Compared to all users, a BARB and BZD were defined as having the following 8-digit American smaller percent of older users had PDEs for either LA BZD only Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Number of LIS PDEs
7,763,277 (2.30%) (6.1%) or both BZD types Classification codes Total prescription cost (million)
<65 years old, Drug type
AHFS Code Description
Number of users
4,905,445 (17.00%) Barbiturates (Anticonvulsants) Low Income Subsidy CONCLUSIONS
Bar biturates
Barbiturates (Anxiolytic, Sedative/Hypnotic) Figure 1. Characteristics of Barbiturate PDEs
Benzodiazepines (Anticonvulsants) BARB and BZD constituted almost 3% of all PDEs with the majority being BZD. Benzodiazepines (Anxiolytic, Sedative/Hypnotic) Figure 4. Benzodiazepine PDEs by Pharmacy Dispensing Type and Prescriber Specialty
These PDEs were used by 7 million Medicare beneficiaries, of whom almost 5 million were beneficiaries 65 and older. Excluded drugs that were previously covered by Medicare Part D program • Phenobarbital and SA/IA BZDs were the most common BARB and BZD drugs. – e.g., Primidone and Butalbital combination drugs for BARB and ≥65 years old, 46.2% Geriatric Medicine, 1.6% Chlordiazepoxide combination drugs for BZD • Although retail pharmacies accounted for the most PDEs, LTC pharmacies accounted for 31.3% and 11.5% of BARB and BZD PDEs. Final list of drugs included for BARB and BZD Phenobarbital, 99.8% • The majority of the BARB and BZD PDEs were prescribed by primary care Psychiatry, 15.8% physicians, NPs/PAs followed by neurologists for BARB or psychiatrists for BZD. Drug Type
Included Drugs
<65 years old, 53.8% • Implication for Policy or Practice: Further investigation is needed to assess if Amobarbital, Butabarbital, Mephobarbital, Pentobarbital, these drugs were used appropriately in the older beneficiaries and if the use of Phenobarbital, Secobarbital these drugs has an impact on outcomes. Alprazolam, Chlordiazepoxide, Clobazam, Clonazepam,
Clorazepate, Diazepam, Estazolam, Flurazepam, Lorazepam,
Low Income Subsidy Midazolam, Oxazepam, Quazepam, Temazepam, Triazolam
REFERENCE
• Phenobarbital was the most prevalent barbiturate with butabarbital and Bold = Long-acting BZD and Maroon = short or intermediate-acting BZD according to the 2012 Beers' The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers secobarbital accounted for the remaining PDEs. Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012. DOI: 10.1111/j.1532- Italics = not included in 2012 Beers' criteria but midazolam is a short-acting BZD and clobazam is a 5415.2012.03923.x long-acting BZD. • The mean ± SD number of PDE per BARB user was 8.7±5.9. Pharmacy Dispensing Type Prescriber Specialty Funding source: Centers for M edicare and Medicaid Services Contact information: [email protected]

Source: https://www.ccwdata.org/cs/groups/public/documents/training/academyhealth_2015_poster5.pdf