Association Between US News & World Report Medical School Ranking and Physician Opioid Prescribing for New Low Back
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J Gen Intern Med DOI: 10.1007/s11606-019-05444-2 © Society of General Internal Medicine 2019
INTRODUCTION
Prior research has found significant physician variation in opioid prescribing.1 Some research has found that primary care physicians (PCPs) who attended a higherranked medical school wrote significantly fewer opioid prescriptions overall than PCPs who attended a lowerranked school.2 Whether an association persists between medical school ranking and opioid prescribing when examining a more clinically defined scenario—patients who develop new low back pain—is unknown.
METHODS
We performed analyses using 2010–2014 claims data for a random 20% sample of Medicare beneficiaries. We included beneficiaries aged 66 and over continuously enrolled in Medicare Parts A, B, and D the year prior, year of, and year subsequent to their episode of new low back pain with no opioid exposure in the prior 365 days. We excluded patients with history of cancer or a hospice claim. The outcome was opioid use in the subsequent 365 days, defined both as a binary variable for ever received and as a continuous variable for the number of morphine equivalents (MEs) received (including zeros for patients who received no opioids). We Received May 22, 2019 Accepted September 26, 2019
converted opioids to MEs using standard conversion tables.3 We focused on PCPs, the greatest prescribers of prescription opioids.2 We defined PCPs as physicians in general practice, family practice, internal medicine, geriatric medicine, and preventive medicine. We obtained medical school attended from the Physician Compare National file.4 We obtained US News & World Report BBest Medical Schools: Research Rankings^ from Schnell and Currie,2 who averaged a school’s rankings from 2010 to 2017 and re-ranked schools according to this average (1 for highest average ranking, 2 for second highest, etc.); 92 schools were ranked. We estimated a multivariable regression (linear probability model for opioid receipt; linear for MEs) of each outcome as a function of ranking (entered categorically). We included physician age and experience, along with current zip code fixed effects to compare physicians of different medical school ranking within the same zip code. We controlled for patient age, sex, race/ethnicity, Elixhauser comorbidity score,5 dual eligibility for Medicaid, and originally being in Medicare for disability; we chose covariates consistent with prior opioid literature.1 We clustered standard errors at the physician level. We tested for a monotonic trend by re-estimating the regression model using categorical ranking as a continuous variable.6 We obtained study approval from the National Bureau of Economic Research, where the data are housed.
RESULTS
The sample included 93,739 patients with new low back pain cared for by 32,102 physicians (Table 1). There was an average of about 1000 patients per ranked medical school. In total, 9.1% of all patients received an opioid and 13.1% of those with two or more visits for new back pain received an opioid.
JGIM
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