We found a match
Your institution may have access to this item. Find your institution then sign in to continue.
- Title
Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia: A Secondary Analysis of a Randomized Clinical Trial.
- Authors
Harnisch, Michelle; Barnett, Michael L.; Coussens, Stephen; Thomas, Kali S.; Olfson, Mark; Berhane, Kiros; Sacarny, Adam
- Abstract
Key Points: Question: Did overprescribing warning letters to high-volume primary care physician prescribers of the antipsychotic quetiapine reduce quetiapine use by their patients with dementia without harming patient health outcomes? Findings: In this secondary analysis of a randomized clinical trial, overprescribing warning letters significantly reduced quetiapine use among patients with dementia living in nursing homes and in the community. There were no detected adverse effects on indicators of cognitive, behavioral, and physical health. Meaning: This study found that warning letters informed by behavioral science can safely reduce overprescribing to patients with dementia, and related interventions may be broadly useful in promoting guideline-concordant care. This secondary analysis of a randomized clinical trial examines whether warning letters to high prescribers of quetiapine are associated with reduced prescribing to patients with dementia and investigates the impacts on patients' health outcomes. Importance: Antipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population. Objective: To determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients' health outcomes. Design, Setting, and Participants: This is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024. Interventions: PCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare. Main Outcomes and Measures: The primary outcome of this analysis was patients' total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community. Results: Of the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, –0.7 days; 95% CI, −1.3 to −0.1 days; P =.02) and community-dwelling patients (adjusted difference, −1.5 days; 95% CI, −1.8 to −1.1 days; P <.001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, −0.01 to 0.03; P =.19), behavioral symptoms (agitated or reactive behavior adjusted difference, −0.2%; 95% CI −1.2% to 0.8% percentage points; P =.72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death. Conclusions and Relevance: This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care. Trial Registration: ClinicalTrials.gov Identifier: NCT05172687
- Subjects
CLINICAL medicine; MEDICAL prescriptions; SECONDARY analysis; HEALTH insurance reimbursement; INDEPENDENT living; RESEARCH funding; MEDICARE; STATISTICAL sampling; QUESTIONNAIRES; KEY performance indicators (Management); RANDOMIZED controlled trials; BEHAVIOR; MULTIVARIATE analysis; DESCRIPTIVE statistics; OVERTREATMENT; NURSING care facilities; COMMUNICATION; PHYSICIANS; DEMENTIA; CONFIDENCE intervals; DATA analysis software; QUETIAPINE; DEMENTIA patients; DRUG utilization; COGNITION; REGRESSION analysis
- Publication
JAMA Network Open, 2024, Vol 7, Issue 1, pe247604
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.7604