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Original Investigation
October 2018

Effect of Peer Comparison Letters for High-Volume Primary Care Prescribers of Quetiapine in Older and Disabled Adults: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
  • 2Office of Evaluation Sciences, US General Services Administration, Washington, DC
  • 3National Bureau of Economic Research, Cambridge, Massachusetts
  • 4Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 5Center for Program Integrity, Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Baltimore, Maryland
  • 6retired from the Center for Medicare, Centers for Medicare & Medicaid Services, US Department of Health and Human Services, Baltimore, Maryland
  • 7currently with The Lab @ DC, Government of the District of Columbia, Washington, DC
  • 8currently with the National Quality Forum, Washington, DC
JAMA Psychiatry. 2018;75(10):1003-1011. doi:10.1001/jamapsychiatry.2018.1867
Key Points

Question  Can behavioral nudges reduce inappropriate prescribing of antipsychotic agents and raise clinical quality for older and disabled patients, who often receive these drugs?

Findings  In this randomized clinical trial, a peer comparison letter randomized across the 5055 highest Medicare prescribers of the antipsychotic quetiapine fumarate reduced prescribing for at least 2 years. Effects were larger than those observed in existing large-scale behavioral interventions, potentially because of the content of the peer comparison letter, which mentioned the potential for a review of prescribing activity.

Meaning  Behavioral nudge interventions can raise the quality of prescribing, but research is still needed on how to most precisely target unsafe prescribing behavior.


Importance  Antipsychotic agents, such as quetiapine fumarate, are frequently overprescribed for indications not supported by clinical evidence, potentially causing harm.

Objective  To investigate if peer comparison letters targeting high-volume primary care prescribers of quetiapine meaningfully reduce their prescribing.

Design, Setting, and Participants  Randomized clinical trial (intent to treat) conducted from 2015 to 2017 of prescribers and their patients nationwide in the Medicare program. The trial targeted the 5055 highest-volume primary care prescribers of quetiapine in 2013 and 2014 (approximately 5% of all primary care prescribers of quetiapine).

Interventions  Prescribers were randomized (1:1 ratio) to receive a placebo letter or 3 peer comparison letters stating that their quetiapine prescribing was high relative to their peers and was under review by Medicare.

Main Outcomes and Measures  The primary outcome was the total quetiapine days supplied by prescribers from the intervention start to 9 months. Secondary outcomes included quetiapine receipt from all prescribers by baseline patients, quetiapine receipt by patients with low-value or guideline-concordant indications for therapy, mortality, and hospital use. In exploratory analyses, the study followed outcomes to 2 years.

Results  Of the 5055 prescribers, 231 (4.6%) were general practitioners, 2428 (48.0%) were in family medicine, and 2396 (47.4%) were in internal medicine; 4155 (82.2%) were male. All were included in the analyses. Over 9 months, the treatment arm supplied 11.1% fewer quetiapine days per prescriber vs the control arm (2456 vs 2864 days; percentage difference, 11.1% fewer days; 95% CI, −13.1% to −9.2% days; P < .001; adjusted difference, −319 days; 95% CI, −374 to −263 days; P < .001), which persisted through 2 years (15.6% fewer days; 95% CI, −18.1% to −13.0%; P < .001). At the patient level, individuals in the treatment arm received 3.9% (95% CI, −5.0% to −2.9%; P < .001) fewer days of quetiapine from all prescribers over 9 months, with a larger decrease among patients with low-value vs guideline-concordant indications (−5.9% [95% CI, −8.0% to −3.9%] vs −2.4% [95% CI, −4.0% to −0.9%], P = .01 for test that effects were equal for both patient groups). There was no evidence of substitution to other antipsychotics, and 9-month mortality and hospital use were similar between the treatment vs control arms.

Conclusions and Relevance  Peer comparison letters caused substantial and durable reductions in quetiapine prescribing, with no evidence of negative effects on patients.

Trial Registration  ClinicalTrials.gov identifier: NCT02467933