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), conducted a randomized trial of informative letters aimed at suspected inappropriate prescribers of addictive substances like 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. Findings are published in the March issue of the journal Health Affairs.
[Photo: Dr. Adam Sacarny]
As one of the first studies to evaluate the outcome of an informative letter aimed at reducing potentially inappropriate medical practices, their findings have important ramifications for policymakers seeking to reduce the misuse of prescription drugs.
“Because we used a randomized controlled trial approach with this intervention, we were able to produce gold standard evidence on its effectiveness,” said Dr. Adam Sacarny, assistant professor of health policy and management at Columbia. “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 prescribing of a set of particularly risky drugs called Schedule II controlled substances through the Medicare Part D prescription drug insurance program. Medications in this category—opioids like OxyContin and Percocet or stimulants like amphetamines—are legal to prescribe, but have potential for abuse and dependency. Their work responds to stark 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 research used a data repository at CMS, the organization that administers Medicare, to identify physicians and other practitioners who prescribed many more controlled substances compared to their peers—over 400 percent more, on average. CMS crafted a letter for these prescribers that incorporated insights from behavioral science research, and the researchers evaluated it using a randomized controlled trial 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 CMS’s data repository to track the effect of the letter on prescribing behavior during the following ninety days.
The intervention represents 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,” noted Dr. Sacarny. “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 now in the field targeting high prescribers of Seroquel, a prescription antipsychotic. According to Dr. Sacarny, “this intervention uses better data and a redesigned letter to build as much as possible on the first round,” he added.
The research was supported by J-PAL North America through the Alfred P. Sloan Foundation and the Laura and John Arnold Foundation. The authors report no conflicts of interest.