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Targeted peer comparison letters effective intervention for quetiapine prescribing
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Peer comparison letters that targeted more than 5,000 high-volume primary care prescribers of the antipsychotic quetiapine resulted in a substantial and durable reduction in their quetiapine prescribing for at least 2 years, findings published in JAMA Psychiatry showed.
“We conducted this research because there are widespread concerns that antipsychotic drugs are overprescribed, especially for older individuals with dementia. These worries persist in spite of guidelines that warn against excessive prescribing in this population,” Adam Sacarny, PhD, assistant professor of health policy and management at Columbia University Mailman School of Public Health, told Healio Psychiatry. “While there are a few tools that seem to help, like intensive education, they are costly and time-consuming. With this study, we wanted to see if a less heavy-handed approach like sending peer comparison ‘review’ letters could be effective.”
Researchers conducted a randomized clinical trial of prescribers and their older and disabled patients nationwide in the Medicare program to determine whether peer comparison letters targeting 5,055 high-volume primary care prescribers of quetiapine in 2013 and 2014 could lead to a reduction in their prescribing of the antipsychotic.
The investigators randomly allocated prescribers (1:1) to receive a placebo letter or three peer comparison letters explaining that their quetiapine prescribing was high compared with their peers. They then assessed total quetiapine days supplied by prescribers from the intervention start (when they received a letter) to 9 months. They also examined quetiapine receipt from all prescribers by baseline patients and quetiapine receipt by patients with low-value or guideline-concordant indications for treatment, mortality and hospital use. In addition, they followed outcomes to 2 years in exploratory analyses.
The analysis included 231 general practitioners, 2,428 prescribers in family medicine and 2,396 in internal medicine.
Over the 9-month period, the treatment arm supplied 11.1% fewer quetiapine days per prescriber than the control arm (95% CI, –13.1 to –9.2; P < .001). This reduction persisted through 2 years, with a cumulative effect of 15.6% (95% CI, –18.1 to –13; P < .001) decrease compared with the control arm. Furthermore, the intervention was linked to a 27.1% decrease in volume of new quetiapine prescriptions over 9 months (95% CI, –31.1 to –23.1; P < .001), which persisted to 2 years (–24.3% relative decrease; P < .001).
“The key takeaway, to me, is that for clinicians aiming to improve prescribing quality in their organizations, peer comparison messages could be a useful and effective tool, particularly if they are paired with a review of previous prescribing activity,” Sacarny told Healio Psychiatry.
When examining the changes at the patient level, Sacarny and colleagues found that participants in the treatment arm received 3.9% fewer days of quetiapine from all prescribers over 9 months (95% CI, –5 to –2.9; P < .001), with a larger drop among patients with low-value indications than guideline-concordant indications (–5.9 vs. –2.4; P = .01). The authors also observed similar 9-month mortality and hospital use between the treatment and control arms.
“With increasing awareness of the dangers of inappropriate prescribing, this study provides evidence that peer comparison letters targeted at high-risk medications could effectively and efficiently create durable improvements in prescribing patterns,” Sacarny and colleagues wrote in the full study.
Physician-focused nudges are advantageous because they can influence routine clinical decisions and actions in a cost-effective way without changing care delivery, Joshua M. Liao, MD, MSc, and Amol S. Navathe, MD, PhD, from the Leonard Davis Institute of Health Economics, University of Pennsylvania, wrote in a related comment.
“While it may be premature to definitively conclude that peer comparison letters can lead to appropriate reductions in rates of quetiapine prescription, the trial by Sacarny et al nonetheless underscores the promise in implementing nudges that are carefully designed and tested to achieve intended effects,” Liao and Navathe wrote. These are important insights for policymakers, health insurers and health systems as they jointly pursue efforts to improve the value of care.” – by Savannah Demko
Disclosure: The authors report no relevant financial disclosures. Navathe reports personal fees from Indegene Inc, Navigant Inc and Navvis and Company; personal fees and equity from NavaHealth; honorarium from Elsevier Press; and grants from Hawaii Medical Services Association and Oscar Health.