Accountability for Inappropriate Antipsychotic Prescribing
A wealth of data has shown in the past that inappropriate drug prescribing in older patients is a common and concerning issue in the United States. Quetiapine prescribing is no exception.
Each year, approximately 2.8 million US patients fill a prescription for quetiapine1― commonly known as Seroquel. Although atypical antipsychotics like quetiapine are indicated for the treatment of schizophrenia, bipolar disorder, and some cases of depression, as much as 75% of quetiapine prescriptions are for off-label uses not approved by the US Food and Drug Administration (FDA).1
YOU MAY ALSO LIKE
Injectable vs Oral Antipsychotics: Which Best Prevents Schizophrenia Relapse?
Study Identifies Groups at Greatest Risk of Dementia
“One of the big areas of overuse is prescribing to older adults with behavioral symptoms of dementia,” said Adam Sacarny, PhD, assistant professor of health policy and management at the Mailman School of Public Health at Columbia University in New York.
“Evidence-based guidelines recommend against prescribing for this purpose except as a last resort, but it still happens quite often,” he said, citing a lack of FDA-approved medications for behavioral symptoms of dementia as a potential reason.
While very common, inappropriate quetiapine prescribing is certainly not free from consequence and can be life-threatening to dementia patients. The FDA requires a black box warning against this practice to be printed on quetiapine labels stating that the drug can raise mortality risk among older adults with the condition.
Cognitive decline, sedation, and movement disorders―or extrapyramidal symptoms―are also among the adverse effects associated with inappropriate quetiapine use in this patient population.
Because of the potential dangers surrounding inappropriate quetiapine prescribing, a better accountability system is likely needed to help reduce these rates and to protect older patients from this practice.
This prompted Dr Sacarny and his team of researchers to test the impact of a peer comparison letter intervention on the rates of quetiapine prescribing among the nation’s highest-volume primary care prescribers.
The findings from their study, which were published ahead-of-print in JAMA Psychiatry, showed great promise.
The Data Speaks Volumes
From 2015 to 2017, Dr Sacarny and his team performed a nationwide randomized clinical trial of Medicare prescribers and their patients. Specifically, their trial focused on the nation’s highest-volume primary care prescribers (n = 5055), which constituted 5% of all primary care prescribers of quetiapine in 2013 and 2014.
Of the prescribers included in the analyses, 4155 (82.2%) were men and 231 (4.6%) were general practitioners, 2428 (48.0%) were in family medicine, and 2396 (47.4%) were in internal medicine.
Each prescriber was randomly assigned to receive either a placebo letter or 3 comparison letters informing them that their quetiapine prescribing was high compared with their peers in the same state who also prescribed quetiapine, and that their prescribing practices were under review by the Medicare program.
The comparison letters also notified recipients that disciplinary actions could be taken against them if their prescribing was deemed abusive.
Total quetiapine days supplied by prescribers from baseline to 9 months comprised the primary outcome of the study. Secondary outcomes were:
- Patients’ receipt of quetiapine from all prescribers at baseline.
- Receipt of quetiapine among patients with low-value or guideline-concordant indications for therapy, mortality, and hospital use.
Overall, Dr Sacarny and colleagues found that the peer comparison letters brought about positive changes, writing that the intervention led to “substantial and durable reductions in quetiapine prescribing” among providers in the study. Moreover, no evidence of negative effects from the intervention was observed among patients, they noted.
Over the 9-month intervention period, the researchers observed 11.1% fewer quetiapine days per prescriber among those who received peer comparison letters (2456 days) vs those who received a placebo letter (2864 days). This effect was found to persist through 2 years.
Patients of prescribers who received peer comparison letters were prescribed 3.9% fewer days of quetiapine over 9 months. The largest decrease was observed among patients with low-value (-5.9%) vs guideline-concordant indications (-2.4%).
Between-group rates of 9-month mortality and hospital use were similar. Also of note, Dr Sacarny and colleagues found no evidence of substitution to other antipsychotics.
Key Takeaways
Previous studies have demonstrated the effectiveness of the peer comparison approach in other contexts, including tax payment and energy conservation 1, so it comes as no surprise that the approach appeared to work well in reducing inappropriate prescribing.
“This review message may have encouraged the doctors to take the letter more seriously and changed their perception of the incentives of prescribing,” Dr Sacarny told Consultant360.
The success of the peer comparison letter may make it an appealing approach for many clinicians and practices. It is important, though, to consider several factors before applying it in practice.
Because the letters are intended to send a strong message, clinicians may want to be selective in determining which cases and situations actually warrant one.
“These messages may be less effective if they are sent frequently,” Dr Sacarny noted. “So, clinicians should also consider whether they want to send them now or save them for a later day, when a more concerning problem may arise.”
Clinicians should also be cautious of unintended effects of the letters that could have a negative patient-level impact. For example, Dr Sacarny added, they could lead some prescribers to cut back on both low-value and high-value care.
This will likely be an area for further research. “Another big question here is whether future work can target low-value prescribing without reducing high-value prescribing,” he said. "A closely targeted intervention would be especially useful.”
Future studies will also involve tailoring the letters to target other forms of inappropriate and over-prescribing. In fact, these letters could soon also play a role in fighting the US opioid epidemic, as Dr Sacarny and his team are currently adapting the letters to target dangerous opioid prescribing.
Adam Sacarny, PhD, is an assistant professor of health policy and management at the Mailman School of Public Health at Columbia University in New York, NY. He is also a faculty research fellow at the National Bureau of Economic Research and an affiliate of the Abdul Latif Jameel Poverty Action Lab at the Massachusetts Institute of Technology in Cambridge, MA.
―Christina Vogt
Reference:
Sacarny A, Barnett ML, Le J, et al. Effect of peer comparison letters for high-volume primary care prescribers of quetiapine in older and disabled adults: a randomized clinical trial [Published online August 1, 2018]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2018.1867