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Long-term interventions needed to reduce inappropriate antibiotic prescribing
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Inappropriate antibiotic prescribing rates increased 12 months after behavioral interventions stopped when compared with control practices, according to findings recently published in JAMA.
“At least one in three antibiotic prescriptions for acute respiratory infections in the U.S. is unnecessary,” Jason N. Doctor, PhD, department chair of health policy and management at the University of Southern California, Los Angeles, told Healio Family Medicine.
“Unnecessary antibiotics can harm and increase antibiotic resistance,” he added. “Initial efforts to curb unnecessary prescribing of antibiotics relied on education, reminders and alerts — none of which were very successful. Our research group turned to psychology to determine if social motivation can reduce unnecessary prescriptions.”
According to the research letter, 248 clinicians from 47 primary care practices received education on antibiotic prescribing guidelines for acute respiratory infections.
Clinicians were randomly assigned to zero, one, two or three of the following interventions for 18 months: accountable justifications that prompted clinicians to enter free-text written justifications for the prescription; peer comparisons that included monthly emails comparing the clinician’s inappropriate antibiotic prescribing rates to those with the lowest rates; and suggested alternatives that showed order sets offering nonantibiotic treatments when clinicians attempted to prescribe antibiotics.
According to study background, the primary outcome was the rate of inappropriate antibiotic prescribing among office visits by adult patients for influenza, acute bronchitis and nonspecific upper respiratory tract infections, while data 12 months after the intervention served as a secondary objective.
During the postintervention period, results indicated that for control clinics, which received only the guideline education, the inappropriate antibiotic prescribing rate decreased from 14.2% to 11.8%.
In addition, results for the intervention groups were as follows:
•Peer comparison increased from 4.8% to 6.3% (difference-in-differences, 3.9%; 95% CI, 1.1-6.7).
•Accountable justification increased from 6.1% to 10.2% (difference-in-differences, 6.5%; 95% CI, 4.2-8.8).
•Suggested alternatives nonsignificantly increased from 7.4% to 8.8% (difference-in-differences, 3.8%; 95% CI, –10.3% to 17.9%).
Results also showed that during the postintervention period, peer comparisons stayed lower than control (P < .001; one-tailed test), but accountable justification was similar (P = .99; one-tailed test).
Researchers suggested that long-term implementation of interventions would reduce inappropriate prescribing.
“While at least some interventions have staying power, effects are diminished to a degree when social motivations are removed,” Doctor said in an interview. “We recommend that nudges remain in place and not be removed, because they are low cost and keeping them in place will likely maintain greater effectiveness.” by Janel Miller
Disclosures: Doctor reports receiving consulting fees from Precision Health Economics. Please see the research letter for all other authors’ relevant financial disclosures.
Perspective
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C. Buddy Creech, MD, MPH
This research letter is a great example of how medicine, like many other professions, is about community. As a result, clinicians are accustomed to sharing their experiences with one another, including best practices, and using each other’s data to guide clinical decisions. Over time, individual behaviors change to match the community.
Through the use of electronic medical records, there has been a move toward automated alerts aimed at altering our behaviors, whether as a pop-up banner that suggests a certain drug in a specific situation or a best practice alert that provides instant feedback; as a result, there is a lot of opportunity for electronic means of behavioral modification. This research letter suggests that these modifications work, but only for as long as that entity is being deployed. If we want durable change, we need to build the community within our individual practices and within our practice networks to see what others are doing. By doing so, we may be able to drive more durable behavioral modification.
This letter is also an example of why medicine has had such a heavy emphasis on apprenticeship as a way of training. Although we have a great fund of knowledge upon completing medical school, we recognize that additional years of “on-the-job” training (anywhere from 3-7 years) are required to hone our craft. This research letter would suggest that even for those who have been in practice for a long period of time, there is ongoing sharpening of our clinical tools that must occur.
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