Antipsychotics are frequently prescribed to older adults with Alzheimer?s disease and related dementias (ADRD) to treat behavioral symptoms, but clinical guidelines suggest their use should be limited in this population due to the possibility of adverse side effects. Recently, interventions have harnessed tools of behavioral economics such as ?nudges? through letters and e-mails to raise prescribing quality. Organizations can deploy these interventions quickly, cheaply, and at scale. However, little evidence exists on using this work to address antipsychotic prescribing to patients with ADRD in spite of the enormous potential value it could have in this context. Moreover, even where evidence exists that interventions successfully cause ?deprescribing?, given the possibilities for patient harms from indiscriminate cutbacks, these interventions merit careful evaluation. Our proposed study seeks to fill this evidence gap. We will analyze a novel trial conducted by the Centers for Medicare and Medicaid Services that randomized over 5,000 high-volume primary care physician prescribers of quetiapine, the most commonly used antipsychotic in the U.S., to overprescribing letters informed by behavioral economics. The letters included a peer comparison ?nudge? and an overuse warning, and they reduced new initiations of quetiapine by 24% over two years. Our work focuses on the effects of these letters on clinical quality, quality of life, and health care use of dementia patients of these physicians. The physicians had over 40,000 patients with ADRD, a large cohort that will facilitate detection of both benefits and harms of deprescribing. We will exploit rich Medicare data, including nursing home assessments and health care claims, and will study effects for up to 5 years. We will proceed in three steps.
In Aim 1, we will analyze effects of the intervention on ADRD patients of study prescribers who live in nursing homes, a particularly vulnerable population for whom extensive data on patient- centered outcomes is available. Through this data, we will closely track clinical and quality of life outcomes, including cognitive function, behavioral symptoms, and depression.
In Aim 2, we will broaden our analyses to include dementia patients who live in the community, using claims data to track effects on health outcomes such as hyperlipidemia and stroke and health care use such as inpatient hospitalizations and primary care visits. Finally, in Aim 3 we will test whether effects of the letters differ for patients based on care setting, sociodemographic group, or nursing home quality; these results will show whether letters address or expand gaps in care quality and will determine which groups, if any, are appropriate for similar interventions in the future. Taken together, our results will show whether simple, behaviorally informed deprescribing efforts can encourage guideline-concordant care and improve outcomes for patients with dementia, or whether such interventions lead to unintended harms. Our findings will guide future policy on deploying low-cost and scalable interventions to improve the quality of care for older adults with ADRD.
The use of antipsychotics in older adults with Alzheimer?s disease and related dementias is commonplace and a key focus of efforts to improve quality of care in this vulnerable population. The goal of this research is to study how a novel effort to use behavioral economics to reduce prescribing of antipsychotics, conducted as a randomized controlled trial of warning letters to high-prescribing physicians, affected the health and quality of life of patients with dementia. Our results will show whether simple interventions can improve the value and safety of the health care system, particularly in dementia care.
