Effect of New York State Regulatory Action on Benzodiazepine Prescribing and Hip Fracture Rates

16 January 2007 | Volume 146 Issue 2 | Pages 96-103

Background: Medicare Part D excludes benzodiazepines from coverage, and numerous state government policies limit use of benzodiazepines. No data indicate that such policies have decreased the incidence of hip fracture.

Objective: To assess whether a statewide policy that decreased the use of benzodiazepines among elderly persons by more than 50% has decreased the incidence of hip fracture.

Design: A quasi-experiment comparing changes in outcomes before and after a policy change in a study U.S. state (New York) and a control state (New Jersey).

Setting: Two U.S. state Medicaid programs, 1988–1990.

Patients: Medicaid enrollees in New York (n = 51 529) and New Jersey (n = 42 029) who received or did not receive a benzodiazepine.

Measurements: Benzodiazepine prescribing and hazard ratios for hip fracture, adjusted for age and eligibility category.

Intervention: A statewide policy, implemented in New York in 1989, that required triplicate forms for benzodiazepine prescribing to allow surveillance by health authorities.

Results: The triplicate prescription policy immediately resulted in a 60.3% (95% CI, –66.3% to –54.2%) reduction in benzodiazepine use among women and 58.5% (–64.3% to –52.8%) among men. Benzodiazepine use in New Jersey remained stable. Hazard ratios for hip fracture that were adjusted for age and eligibility category did not change in New York or New Jersey when the periods before and after use of the triplicate prescription policy were compared (change from 1.2 to 1.1 among female benzodiazepine recipients [P = 0.70], 1.3 to 1.1 [P = 0.08] among female nonrecipients, 0.8 to 1.1 [P = 0.56] among male recipients, and 1.1 to 1.3 [P = 0.46] among male nonrecipients).

Limitations: Information was lacking on race, benzodiazepine dose, and other potential determinants of continued benzodiazepine prescribing.

Conclusions: Policies that lead to substantial reductions in the use of benzodiazepines among elderly persons do not necessarily lead to decreased incidence of hip fracture. Limitations on coverage of benzodiazepines under Medicare Part D may not achieve this widely assumed clinical benefit.

Editors' Notes Context Early studies showed that benzodiazepine use was associated with increased rates of hip fracture. Soon after, New York State adopted legislation to control benzodiazepine prescriptions. New Jersey did not. Contribution The authors observed rates of benzodiazepine prescribing and hip fractures in Medicaid patients for 12 months before and 21 months after New York began to track rates of physicians' benzodiazepine prescribing. Prescription rates decreased abruptly by 60%, but hip fracture rates did not change. In New Jersey, concurrent hip fracture rates did not change. Caution Prescribed dosages of benzodiazepines were unknown. Implication Controlling benzodiazepine prescribing may not reduce hip fractures, possibly because the 2 are not causally related. —The Editors

 

Author and Article Information

From Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts; Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Foundation, and Fallon Community Health Plan, Worcester, Massachusetts; JEN Associates, Inc., Cambridge, Massachusetts; and Albany College of Pharmacy and Management Reports & Research Unit, Office of Medicaid Management, New York State Department of Health, Albany, New York.

Disclaimer: The conclusions derived in this manuscript are those of the authors and not of the New York State Department of Health.

Acknowledgments: The authors thank Dr. Woopill Hwang for facilitating the extract of New York Medicaid data; Joyce Cheatham, Robert LeCates, Mai Manchanda, and Ann Payson for administrative support; and Dr. Sebastian Schneeweiss for insightful comments on an earlier version of the manuscript.

Grant Support: From the National Institute on Aging (grant R01 AG19808-01A1; principal investigator, Stephen B. Soumerai) and the National Institute on Drug Abuse (grant R01DA10 371-01; principal investigator, Stephen B. Soumerai). Drs. Wagner, Soumerai, Ross-Degnan and Gurwitz were also investigators in the HMO Research Network Centers for Education and Research on Therapeutics Prescribing Safety Study (Agency for Health Care Research and Quality Cooperative Agreement U 18 HS 11843; principal investigator, Richard Platt).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Stephen B. Soumerai, ScD, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215; e-mail, ssoumerai{at}hms.harvard.edu.

Current Author Addresses: Drs. Wagner, Ross-Degnan, Zhang, and Soumerai: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215.

Dr. Gurwitz: Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Foundation, and Fallon Community Health Plan, 630 Plantation Street, Worcester, MA 01605.

Mr. Gilden: JEN Associates, Inc., 5 Bigelow Street, Cambridge, MA 02139.

Dr. Cosler: Albany College of Pharmacy, 106 New Scotland Avenue, Albany, NY 12208.

Author Contributions: Conception and design: A.K. Wagner, J.H. Gurwitz, S.B. Soumerai.

Analysis and interpretation of the data: A.K. Wagner, D. Ross-Degnan, F. Zhang, D.B. Gilden, L. Cosler, S.B. Soumerai.

Drafting of the article: A.K. Wagner, D. Ross-Degnan, S.B. Soumerai.

Critical revision of the article for important intellectual content: A.K. Wagner, D. Ross-Degnan, J.H. Gurwitz, F. Zhang, D.B. Gilden, L. Cosler, S.B. Soumerai.

Final approval of the article: A.K. Wagner, D. Ross-Degnan, J.H. Gurwitz, F. Zhang, S.B. Soumerai.

Provision of study materials or patients: L. Cosler.

Statistical expertise: F. Zhang.

Obtaining of funding: A.K. Wagner, S.B. Soumerai.

Administrative, technical, or logistic support: S.B. Soumerai.

Collection and assembly of data: D. Ross-Degnan, D.B. Gilden, L. Cosler, S.B. Soumerai.

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