#362 2017 · San Diego County Medical Examiner's Office · Public health / medicineattack-invisible-cost
Doctors kept prescribing opioids to patients who later overdosed, and never found out — so the county coroner started telling them, one named patient at a time.
the problem
professionals make decisions whose harmful downstream consequences they never see, so nothing in their own feedback loop pushes them to change behavior
background
Physicians prescribing opioid painkillers rarely learned what happened to a specific patient after that patient left their care — if a patient later died of an overdose, potentially involving the very medication the doctor had prescribed, the doctor typically never found out. This meant no direct feedback loop existed between a prescribing decision and its worst possible outcome, leaving physicians to continue prescribing based only on aggregate opioid-crisis statistics in the news, an abstraction easy to feel disconnected from one's own specific patients.
The San Diego County Medical Examiner's Office, which certifies cause of death for overdose cases, held information no prescriber ever received: the direct link between a specific doctor's specific patient and that patient's overdose death. Rather than let that information remain purely a public health statistic, the office decided to close the loop directly with the individual prescribers involved.
the move
Starting in January 2017, the medical examiner's office began mailing 'Dear Doctor' letters to nearly 400 individual clinicians whose patients had died of a prescription drug overdose, naming the specific patient and stating plainly that the overdose was the primary or contributing cause of death, alongside five evidence-based prescribing recommendations shown to reduce overdose risk.
the payoff
A randomized study of the intervention, published in the journal Science in 2018, found opioid prescribing among letter recipients dropped 6.2 to 13.2 percent relative to non-recipients, with an initial roughly 10% reduction at three months settling to a still-significant 7% reduction that held for at least a full year after receiving the letter — a durable behavior change driven entirely by making one abstract statistic into one named, real patient.
what came after
The Dear Doctor letter intervention is now cited as a landmark, rigorously studied case in behavioral public health for how personalizing an abstract harm — naming the specific person affected by a professional's decision — can change behavior more effectively and durably than general risk-awareness campaigns, and versions of the same personalized-feedback letter approach have since been adopted by public health departments and prescription monitoring programs in other jurisdictions confronting the opioid crisis.
references
- [1]Doctors nudged by overdose letter prescribe fewer opioidsUS News & World Report / AP, 2018usnews.com
- [2]Sending letters about their patients' overdoses changes doctors' prescribing habitNPR, 2018npr.org