Behavior modification might curb antibiotic overprescribing

Old-fashioned behavior modification may be a useful tool in the effort to get medical providers to stop prescribing unnecessary antibiotics, according to a study published Tuesday.

The USC-led team of researchers found that certain behavioral "nudges" appeared to lead to modest but significant reductions in the number of prescriptions providers ordered for acute respiratory infections that should not be treated with antibiotics.

Overprescription of antibiotics has contributed to the appearance of treatment-resistant infections. According to the study, published Tuesday in JAMA, there are more than 22 million inappropriate prescriptions in the U.S. every year for acute respiratory infections, such as the common cold.

"Until now, most efforts to reduce antibiotic prescribing have involved education, reminders or giving financial incentives to physicians," said principal investigator and senior author Jason Doctor, director of health informatics for the USC Schaeffer Center for Health Policy and Economics. "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."

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The researchers studied 248 clinicians – doctors, physician assistans and nurse practitioners – at 49 primary care practices in Massachusetts and Southern California (AltaMed Medical Group and The Children’s Clinic, which also sees a large number of adult patients).

The study focused on how these providers handled acute respiratory infections that should not be treated with antibiotics. After an 18-month control period, the researchers tracked the clinicians’ prescribing decisions for more than 30,000 patients over another 18 months.

The study gave the clinicians one or more of three behavioral "nudges."

The most successful "nudge" involved "accountable justification," according to the study. When a provider would order antibiotics, a prompt would appear on the patient’s electronic chart asking the clinician to justify the prescription. The justification would be added to the chart unless the provider cancelled the order.

The second-most successful approach was "peer comparison." Clinicians received an email showing how they ranked in comparison with their counterparts’ prescribing records. Those with the lowest rates of unnecessary prescriptions were rated "top performers" and were told "congratulations." Those who did not score well were rated "not a top performer" and received a count of their inappropriate prescriptions.

Those two interventions together prevented on average one inappropriate prescription for every eight patients seen, the study concluded.

Another "nudge" suggested alternative treatments. When a provider ordered an unnecessary antibiotic for an acute respiratory infection, a box would appear on his computer suggesting alternative treatments. This approach also led to a reduction in inappropriate prescriptions, but the study concluded that the decrease was not statistically significant.

"There was much more variability" in the data from the approach using suggested alternatives, "so we were not as confident in that result as we were with the other interventions," Doctor told KPCC.

The researchers acknowledged the study had limitations. For example, it tracked a relatively small number of clinicians, and using more than one "nudge" could have weakened the effects of the approach.

While the reductions in prescribing rates apparently achieved by the study "were modest, they are real, important, and potentially sustainable," Dr. Jeffrey Gerber of the division of infectious diseases at The Children’s Hospital of Philadelphia wrote in an accompanying JAMA editorial.

Gerber said the research builds on the results of a previous study that found a 20 percent reduction in inappropriate prescriptions for acute respiratory tract infections after researchers posted a letter in exam rooms signed by the provider committing himself to reducing unnecessary prescriptions.

He called for further research, including studies focused on "the most common infections for which antibiotics are sometimes (but often not) indicated, such as acute pharyngitis and sinusitis."