Behavioral Nudges Lead to Drop in Prescriptions of Potent Antipsychotic
A study led by a researcher at Columbia University’s Mailman School of Public Health has found that letters written to frequent prescribers of Seroquel (quetiapine), an antipsychotic with potentially harmful side effects in the elderly, significantly reduced the number of prescriptions for Medicare patients. The results showed that the letters, which informed physicians of their relatively high volume of Seroquel prescriptions, led to statistically meaningful, persistent decreases in the number of prescriptions they wrote for the drug, with no detected negative effects on patients. The findings are online in JAMA Psychiatry.
“Our study provides a unique example of a large-scale, low-cost intervention yielding clinically meaningful and long-lasting effects,” says Adam Sacarny, PhD, assistant professor of Health Policy and Management at Columbia’s Mailman School of Public Health and first author. The work was conducted with the Office of Evaluation Sciences in the General Services Administration (CMS), which promotes evaluation and testing in the federal government; the Centers for Medicare and Medicaid Services; and researchers at the Harvard T.H. Chan School of Public Health.
The randomized controlled trial targeted the 5,055 highest Seroquel-prescribing primary care physicians nationwide in the Medicare Part D (prescription drug coverage) program in 2013 and 2014. A random half of the doctors were assigned to the treatment arm and received three letters comparing their prescribing practices to their peers; the other half received placebo letters about an unrelated Medicare regulation. The treatment arm’s letter stated that the physician’s high volume of prescribing of Seroquel relative to their peers and was under review. The text also discussed that high Seroquel prescribing could be appropriate but was concerning for medically unjustified use. The letter encouraged physicians to review their prescribing patterns.
Physicians who got peer comparison letters dropped their overall Seroquel prescribing by 11 percent over the next nine months and 16 percent over the next two years. New initiations of Seroquel dropped even more: 24 percent over two years.
“Our findings show that for healthcare organizations and clinicians aiming to improve the quality of prescribing, peer comparison messages could be useful and effective tools, particularly when they are paired with a review of previous prescribing activity,” says Sacarny. “Similar messages could address over-prescribing of other drugs, like opioids, or they could target care that goes against clinical guidelines.”
The researchers also followed patients treated by physicians in the study. On average, patients of physicians who received peer comparison letters were given 6 percent fewer days of Seroquel over two years. Patients with a history of dementia, where guidelines discourage Seroquel prescribing, experienced a larger reduction of 8 percent fewer days of Seroquel. There was no evidence of adverse effects on patients due to the letters: use of the emergency department, hospitalizations, and mortality were similar for patients of physicians in both arms of the study.
Seroquel is frequently prescribed “off-label,” or outside its FDA-approved indications, for patients with dementia or Alzheimer’s disease despite a large body of evidence that it is associated with significant harm in these populations. Guidelines from the American Psychiatric Association and the American Geriatrics Society discourage this overuse of antipsychotics including Seroquel. This off-label use against guidelines has attracted the attention of the Centers for Medicare & Medicaid Services and federal oversight agencies.
“Overprescribing of antipsychotic drugs is a huge and persistent problem, particularly in the elderly,” says Michael Barnett, MD, of the Harvard T.H. Chan School of Public Health, the second author on the study. “We think our results are striking for something as simple and cheap as sending letters. Beyond the benefit in reducing anti-psychotic use, the intervention could also have implications for how we can nudge physician behavior more broadly.”
Sacarny and colleagues showed that with the increasing need to address the dangers of inappropriate prescribing, peer comparison letters targeted at high-risk medications provide one way to efficiently create lasting changes in prescribing patterns.
Co-authors are Michael Barnett of the Harvard T.H. Chan School of Public Health; Jackson Le, Frank Tetkoski, and Shantanu Agrawal of the Centers for Medicare and Medicaid Services; and David Yokum of the Office of Evaluation Sciences. Tetkoski is now retired, Agrawal is now President and CEO of the National Quality Forum, and Yokum is now director of the Lab @ DC.
The study was supported by the Robert Wood Johnson Foundation, the Abdul Latif Jameel Poverty Action Lab North America, and the Laura and John Arnold Foundation. The authors declare no conflicts.
More information about the project can be found online through the Office of Evaluation Sciences in the General Services Administration.