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'Nudges' lower rates of inappropriate antibiotic prescriptions
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The use of certain behavioral interventions, or so-called “nudges,” significantly lowered the rates of inappropriate antibiotic prescribing for acute respiratory tract infections among primary care practices, according to a study published in JAMA.
The study built upon prior research showing that poster-sized “commitment letters” posted in examination rooms during peak cold and influenza season had a similar effect.
“Until now, most efforts to reduce antibiotic prescribing have involved education, reminders or giving financial incentives to physicians,” researcher Jason N. Doctor, PhD, director of health informatics for the University of Southern California Schaeffer Center for Health Policy and Economics, said in a news release. “We decided to test if socially motivated interventions, such as instilling pride in their performance or making physicians accountable for their decisions, would help address the problem. Our findings here suggest they may.”
Jason N. Doctor
Two of three ‘nudges’ prove effective
Doctor and colleagues evaluated three behavioral interventions — accountable justification, peer comparison and suggested alternatives — and determined that the first two significantly reduced the number of inappropriately prescribed antibiotics for acute respiratory tract infections.
They conducted a randomized clinical trial among 47 primary care practices in Boston and Los Angeles comprising 248 enrolled clinicians randomly assigned up to three interventions for 18 months between 2011 and 2014. Adult patients with comorbidities and concomitant infections were excluded.
There were 125,333 visits for any diagnosis of acute respiratory tract infection, of which 31,712 adults met study criteria — 14,753 during the baseline period and the remainder during the intervention period.
Data showed that accountable justification, in which clinicians received an electronic health record prompt asking them to justify their treatment decision, was the most successful intervention. It reduced antibiotic prescription rates by 18.1%.
Peer comparison also was beneficial, reducing antibiotic prescription rates by 16.3%. The email-based intervention ranked clinicians according to their rate of inappropriate antibiotic prescriptions and identified them as “top performers” or “not a top performer.”
The researchers, however, saw no statistically significant effect in the third intervention that provided EHR pop-up boxes encouraging alternative treatments whenever a clinician recorded an antibiotic prescription for acute respiratory infection, but had no social component.
“For some primary care practices, the peer comparison intervention might be the simplest and most pragmatic of these interventions, since it requires no modification of the EHR,” Doctor and colleagues wrote. “However, the peer comparison intervention depends on producing valid performance measures, which can be challenging when data are unavailable or individual-clinician sample sizes are small. The accountable justification intervention, although it requires EHR modification, does not have these drawbacks and can, in theory, be applied to any clinical decision (since clinicians should always be able to articulate a decision-making rationale).”
Need for a national database
In a related editorial, Jeffrey S. Gerber, MD, PhD, attending physician in the division of infectious diseases at The Children’s Hospital of Philadelphia, said clinicians should be required to justify every antibiotic order and should be compared with their top-performing peers. Gerber said wide use of EHR in outpatient care showed that a national database could allow for benchmarking antibiotic prescribing for the most common acute respiratory tract infections.
“This approach would provide an invaluable tool for broad dissemination of this outpatient antimicrobial stewardship intervention and for reducing the patient harm caused by the overuse of antibiotics,” he wrote.
‘Commitment letters’ produce similar effect
A 2014 study by Doctor and colleagues showed that a simple reminder in the form of signed letters resulted in a 20% reduction in inappropriate prescriptions for acute respiratory infections.
The letters, displayed in examination rooms, featured photographs and signatures of clinicians who stated their commitment to avoid inappropriate antibiotic treatments for acute respiratory infections.
The researchers calculated that the intervention could eliminate 2.6 million unnecessary antibiotic prescriptions and save up to $70.4 million in drug costs annually.
References:
Gerber JS. JAMA. 2016;doi:10.1001/jama.2016.0430.
Meeker D, et al. JAMA. 2016;doi:10.1001/jama.2016.0275.
Meeker D, et al. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2013.14191
Disclosures: The researchers and Gerber report no relevant financial disclosures.
Perspective
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Jesse T. Jacob, MD
Meeker and colleagues tested three “nudges” in outpatient settings to improve antibiotic prescribing, and their findings provide important insights into how to promote stewardship in ambulatory medicine.
Two interventions were similarly effective (monthly peer benchmarking via email and requiring an indication for antibiotics) with about 17% decreases in inappropriate antibiotic prescriptions for upper respiratory tract infections to less than 5%, while the third (alternative therapies prompted in the electronic medical record) was no different than the control groups. A single monthly email is an attractive, low-cost and efficient method to influence antibiotic prescribing behavior among busy clinicians compared with pop-ups in the electronic medical record (EMR, whether indications or alternatives). Some unintended consequences such as alert fatigue (missed critical alerts), lower patient or provider satisfaction, or lost provider time even with one to two additional clicks in the EMR-based interventions were not assessed. There was a small, but statistically significant increase in the number of return visits from the control group to the accountable justification-peer benchmarking combined group (0.4% vs. 1.4%) but no evidence of “diagnosis switching.” While this randomized control trial has some limitations, if feeding back antibiotic prescriptions rates is truly this effective, practices should now consider how to implement this simple, low-cost intervention as a quality improvement initiative. What’s less clear is whether this applies to all types of practices, syndromes, and whether antibiotics were concordant with guidelines (not only indication, but duration and selection).
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