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Awareness of patient harm increases physician support of fines for antibiotic overprescribing

Physician support of financial penalties for inappropriate antibiotic prescribing varied by whether patient, societal or institutional harms were presented as the rationale, with patient harms being the most persuasive, according to survey data published in Annals of Internal Medicine.

“Physicians commonly prescribe antibiotics for uncomplicated upper respiratory infections despite consensus about their low value and efforts emphasizing their societal costs and harms,” Joshua M. Liao, MD, MSc, from the University of Pennsylvania, and colleagues wrote. “To deter low-value services, policymakers have begun proposing financial penalties for physicians who prescribe them.”

Liao and colleagues conducted a web-based survey of ACP members to determine if patient, societal or institutional harms of inappropriate antibiotic prescribing affects physician support of financial penalties for antibiotic misuse. Subspecialists, retirees and those who do not see patients were not included. The researchers measured the likelihood of respondents to prescribe antibiotics to treat uncomplicated upper respiratory infections using a clinical vignette. Attitudes towards cost control in patient care was also assessed.

The participants answered one of four versions of the principal question, which gauged how likely respondents were to support a policy that financially penalized organizations and physicians for routinely recommending antibiotics for uncomplicated upper respiratory infections. The first three versions stated, “According to research and expert opinion, mild-to-moderate upper respiratory symptoms lasting less than 7 days are frequently due to viruses and therefore resolve on their own,” and each question described either harms to patients (increased costs and iatrogenic infections), society (increased bacterial resistance to antibiotics) or hospitals and insurers as institutions (increased costs). The fourth version served as a control and provided no additional information. Responses were collected using a 5-point scale that defined positive answers as “somewhat likely” and “very likely.”

Nearly half (47%) of 694 eligible respondents completed the survey (mean age, 48 years; 55% male; 90% practicing physicians). Incentives based on cost performance or other factors such as quality or patient satisfaction were reported by 29% and 55% of participants, respectively. Overall, financial penalties were supported by 31% of respondents; however, there was variation by version. A total of 41% of recipients of the patient harm version, 23% of recipients of the societal harm version, 36% of recipients of the institutional harm version and 25% of recipients of the control version supported penalties.

Adherence to guidelines governing inappropriate antibiotic prescription for upper respiratory infections was indicated in 27% of physicians, based on their response to a clinical vignette in the survey. These physicians were more likely to support financial penalties than those who were nonadherent (44% vs. 26%). Respondents who agreed that clinicians should play an active role in cost control were more likely to support penalties than those who disagreed (31% vs. 14%), while respondents who agreed that only clinicians and patients should decide whether a test or treatment is “worth the cost” were less likely to support penalties than those who disagreed (28% vs. 36%).

“Support for financial penalties targeting inappropriate antibiotic prescribing was highest among physicians who received information about patient harms,” Liao and colleagues concluded. “Although more work is needed, these preliminary results suggest that policymakers might increase the acceptability of penalties by implementing them while explicitly emphasizing the harms and costs to patients.” – by Alaina Tedesco

Disclosure: The researchers report receiving support from the Leonard Davis Institute of Health Economics at the University of Pennsylvania.