Peer Pressure Tactic Successfully Curbs Overprescribing

Megan Brooks

August 15, 2018

Peer comparison letters sent to high prescribers of the antipsychotic quetiapine (Seroquel, AstraZeneca) led to a significant reduction in the number of prescriptions written for elderly patients, with no apparent harmful effects on patients, results of a randomized trial show.

"Our results show that simple letters like these can be powerful tools to reduce overprescribing," Adam Sacarny, PhD, assistant professor of health policy and management, Columbia University Mailman School of Public Health, New York City, told Medscape Medical News.

"For healthcare organizations that want to improve clinical quality, letters could be part of the toolkit. Letters are a low-cost approach to addressing issues with quality of care, and they have the benefit of not imposing restrictions on how providers practice medicine, unlike other approaches, like quantity limits," said Sacarny.

The study was published online August 1 in JAMA Psychiatry.

High-Volume Prescribers

The researchers targeted the 5055 highest-volume primary care prescribers of quetiapine in 2013 and 2014 (roughly 5% of all primary care prescribers of quetiapine) with the goal of reducing excessive prescribing to Medicare beneficiaries.

Prescribers were randomly assigned in a 1:1 ratio to receive either three peer comparison letters or "placebo" letters about an unrelated Medicare regulation.

The comparison letters stated that the physicians' quetiapine prescribing was high relative to their peers and was under review. The letters mentioned that high quetiapine prescribing could be appropriate but was raised concern regarding medically unjustified use, and the letters encouraged the primary care physicians to review their prescribing patterns.

Over 9 months, physicians who received peer comparison letters dropped their overall quetiapine prescribing by 11.1% (-319 days; 95% confidence interval [CI], -374 to -263 days; P < .001). The decrease persisted over a period of 2 years (15.6% fewer days; 95% CI, -18.1% to -13.0%; P < .001).

Those patients seen by physicians who received the peer comparison letters received 3.9% fewer days of quetiapine over 9 months (P < .001). A larger decrease was observed among patients with low-value vs guideline-concordant indications (-5.9% vs -2.4%; P = .01).

There was no evidence of substitution of other antipsychotics, and 9-month mortality and hospital use were similar between the treatment arm and the control arm, the researchers report.

"We found that patients who were low-value candidates for Seroquel experienced larger reductions in their receipt of the drug, but we still observed a reduction in use for guideline-concordant patients. However, we did not see signs of adverse effects on guideline-concordant patients when we looked at emergency department use and hospitalizations, and if anything, these patients had fewer of these encounters," Sacarny told Medscape Medical News.

"We also noted that guideline-concordant patients received more Seroquel from psychiatrists, which may have been beneficial for them. While we were only able to look at a few adverse outcomes, the results suggest that prescribers may have been able to focus their cutbacks of Seroquel on patients where doing so made sense clinically," Sacarny said.

This study shows that behavioral nudging can "raise the quality of prescribing, but research is still needed on how to most precisely target unsafe prescribing behavior," the researchers conclude.

Unintended Effects?

The coauthors of a linked editorial note that quetiapine is often prescribed for patients in whom a clear clinical benefit does not exist. Off-label use of quetiapine is associated with a number of adverse events, including risk for death and extrapyramidal symptoms.

"Given growing attention to this problem, the study by Sacarny et al helps fill an important gap by illustrating one potential approach to reducing potentially inappropriate antipsychotic prescribing while improving safety," write Joshua Liao, MD, and Amol Navathe, MD, PhD, from University of Pennsylvania School of Medicine in Philadelphia.

The study serves as a reminder that with any intervention, consideration should be given both to intended and to unintended behavioral responses, the editorialists say.

"For example, additional work is needed to understand any negative implications of intervention letters that reduced quetiapine prescriptions among guideline-concordant as well as low-value patients. Though designed to be subtle, nudges can lead to outsized unintended effects, an issue that may be most relevant for interventions aimed at reducing medical overuse or misuse," they write.

Opioids Another Target

Behavioral nudging may also work for opioid prescribing, according to results of a randomized trial that found that physicians who were informed about patient overdose deaths became more careful in prescribing the painkillers.

The study included 861 clinicians who prescribed medications to 170 patients who subsequently suffered a fatal overdose involving prescription opioids. Half the clinicians were randomly selected to receive a letter from the county medical examiner notifying them that a patient to whom they had prescribed opioids in the past year had had a fatal overdose. The letter, which was supportive in tone, also provided information from the Centers for Disease Control and Prevention on safe prescribing guidelines, nudging clinicians toward better prescribing habits.

In the 3 months after the letter was sent, prescribing decreased by 9.7% among those who received the letter in comparison with the control group of clinicians who did not receive the letter. Furthermore, clinicians who received the letter were 7% less likely to start prescribing an opioid to a new patient and were less likely to prescribe higher doses.

The study was conducted by Jason Doctor, MD, director of health informatics at the Schaeffer Center for Health Policy and Economics, the University of Southern California, Los Angeles, and colleagues and was published online August 10 in Science.

The study by Dr Sacarny and colleagues was supported by the Robert Wood Johnson Foundation, Abdul Latif Jameel Poverty Action Lab (J-PAL) North America, and the Laura and John Arnold Foundation. The authors have declared no conflicts of interest. The study by Dr Doctor et al was funded by the California Health Care Foundation and the National Institute on Aging. The authors have disclosed no relevant disclosures.

JAMA Psychiatry. Published online August 1, 2018. Abstract, Editorial

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