Researchers at Columbia University’s Mailman School of Public Health, with colleagues at the White House Social and Behavioral Sciences Team, the Massachusetts Institute of Technology, and the Centers for Medicare and Medicaid Services (CMS), have conducted a randomized trial of informative letters aimed at suspected inappropriate prescribers of addictive substances, such as opioids and amphetamines. Top prescribers of these substances were identified and sent a letter informing them of their high prescribing rate. The investigators were unable to detect a statistically significant effect of the intervention on prescribing practices. The findings were published online in Health Affairs.
As one of the first studies to evaluate the outcome of an informative letter aimed at reducing potentially inappropriate medical practices, the findings have important ramifications for policymakers seeking to reduce the misuse of prescription drugs, according to the investigators.
“Because we used a randomized controlled trial approach with this intervention, we were able to produce gold standard evidence on its effectiveness,” said Adam Sacarny, PhD, assistant professor of Health Policy and Management at the Mailman School of Public Health. “Even though we weren’t able to show that the letters were effective, this information is still useful for policymakers. This is why it’s so important to rigorously test these interventions. Based on these results, we’re now experimenting with different letter designs and making other changes to see if another approach can yield reductions in overprescribing.”
The researchers focused on the prescribing of schedule II controlled substances through the Medicare Part D prescription drug insurance program. Medications in this category—opioids such as oxycodone (OxyContin, Purdue Pharma) and oxycodone/acetaminophen (Percocet, Endo Pharmaceuticals) or stimulants such as amphetamines—are legal to prescribe in the U.S. but have the potential for abuse and dependency. The researchers’ work responds to trends in the use and associated harms of these drugs—opioid overdose death rates quadrupled between 1999 and 2014, and more than one-third of Medicare Part D enrollees now fill an opioid pain reliever prescription each year.
The new research used a data repository at the CMS to identify physicians and other practitioners who prescribed many more controlled substances compared with their peers—over 400% more, on average. The CMS crafted a letter for these prescribers that incorporated insights from behavioral science research, and the researchers evaluated it using a randomized controlled approach similar to what is used in most medical trials. Of the 1,525 prescribers who were identified as potentially risky and enrolled in the study, a random half were sent the letter. The researchers then used the CMS’s data repository to track the effect of the letter on prescribing behavior during the following 90 days.
The intervention represents the CMS’s first systematic letter campaign seeking to reduce inappropriate practices in the Medicare Part D prescription drug insurance program, although it is an extension of an existing program that provides informative letters with peer comparisons to physicians about their billing behavior. “We could not find any evaluations of the other program, and believe our work fills in that gap,” Sacarny noted. “We also think that our evidence could be useful for other insurers, including other parts of Medicare, when they look to improve their communications with providers.”
“We view these findings as part of a process of continuous improvement. We’ve shown that we can run these evaluations quickly and rigorously,” he continued. “While we didn’t detect an effect of our efforts in this trial, we’re now regrouping for the next round.”
As part of a new study, researchers are targeting high prescribers of quetiapine fumarate (Seroquel, AstraZeneca), a prescription antipsychotic. According to Sacarny, “this intervention uses better data and a redesigned letter to build as much as possible on the first round.”
Sources: Columbia University; March 7, 2016; and Health Affairs; March 7, 2016.