A behavioral “nudge” intervention, targeting primary care prescribers who have particularly high off-label prescription rates of the antipsychotic quetiapine fumarate to older and disabled adults, has shown significant and long-lasting reductions in prescriptions.
A study, published Aug. 1 online by JAMA Psychiatry, looked at the effect of a “peer-comparison” letter, compared with a placebo letter, sent to 5,055 high quetiapine-prescribing primary care physicians in the Medicare program.
The letters said that the physicians’ quetiapine prescribing was extremely high, compared with their peers’ prescribing in the same state. Furthermore, the letters said the high-volume prescribers’ practices were under review because of concerns over medically unjustified use. They also encouraged the doctors to review their prescribing habits, while the placebo letter simply discussed an unrelated Medicare enrollment regulation.
Over the 9-month study, researchers saw a significant 11.1% reduction in the total number days of quetiapine prescribing among physicians who received the intervention letter, compared with those who received the control letter (95% confidence interval, –13.1 to –9.2 days; P less than .001; adjusted difference, –319 days; 95% CI, –374 to –263 days; P less than .001). At 2 years, the cumulative reduction was 15.6% fewer days in the intervention group (95% CI, –18.1 to –13.0; P less than .001), compared with the control group.
The study also used Medicare data to look at the impact on patients and found that individuals whose physicians were in the intervention arm had 3.9% fewer days of quetiapine usage over the 9 months (95% CI, –5.0 to –2.9; P less than 0.11), compared with those in the control arm. The reduction was even greater among patients whose indications for quetiapine were deemed to be of “low value,” as opposed to those who were prescribed for guideline-concordant indications, reported Adam Sacarny, PhD, of Columbia University, New York, and his coauthors.
When researchers looked in more detail at the reductions in prescriptions for guideline-concordant patients, they found that much of this was offset by prescriptions from other prescribers; in particular, physicians with psychiatric specialization or other study prescribers who the patient had not previously received a quetiapine prescription from.
The authors noted that the reductions for guideline-concordant patients could have negative effects if prescribers were reducing their quetiapine prescriptions indiscriminately.
“If this represented a harmful change for patients, we may have expected to see higher rates of adverse outcomes in the guideline-concordant patient group as prescribing rates decreased,” wrote Dr. Sacarny, and his coauthors. “However, if anything, guideline-concordant patients experienced lower rates of hospital encounters after the intervention.”
The study did not see any evidence of substitution to other antipsychotics, nor was any significant difference found in hospital use or mortality between the two arms of the study.
Dr. Sacarny and his coauthors cited several limitations. One is that the analysis looked at prescribing covered by Medicare Part D only. Nevertheless, they said, the results show the impact that peer comparison letters can have on prescribing patterns.
“These results provide encouraging evidence that high prescribers of antipsychotics can decrease quetiapine prescribing, without adverse clinical consequences, in response to a letter highlighting their overall high rates of prescribing,” the authors wrote.
The study was supported by the Robert Wood Johnson Foundation, Abdul Latif Jameel Poverty Action Lab North America, and the Laura and John Arnold Foundation. No conflicts of interest were reported.
SOURCE: Sacarny A et al. JAMA Psychiatry. 2018 Aug 1. doi: 10.1001/jamapsychiatry.2018.1867.