Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial

Abstract

BackgroundClinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.MethodsPrimary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.ResultsWe examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44–0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54–0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53–0.995).ConclusionsWe observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.Trial RegistrationClinicalTrials.gov: NCT01454960.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1715-8) contains supplementary material, which is available to authorized users.

A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings

“…As this was a comparative effectiveness study without a contemporaneous control, we cannot definitively say that the interventions themselves fulfilled a causal role in reducing inappropriate antibiotic prescribing, although the natural trends in Figure suggest they did. Moreover, we did not have a safety endpoint such that we could measure an unintended harm of return visits for pneumonia or other illness progression, although recent empirical evidence suggests that this is unlikely . There is also limited generalizability since all sites were affiliated with academic health centers located in only two states.…”

“…Considerable evidence from economic theory and research in other clinical areas suggests that adding a package of feedback, nudges, and peer comparisons could dramatically improve prescribing outcomes. Our investigative team previously showed that relatively simple interventions, grounded in behavioral economics and decision science, that leverage accountability and social norms, can reduce unnecessary antibiotic prescribing for acute respiratory infection (ARI) in primary care practices . Peer comparisons dramatically improve prescribing outcomes in outpatient clinics and doctor's offices and are sustained for at least 12 months after interventions end .…”

Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial

“…15 This strategy provides participants with information on their own performance compared to their peers to correct misperceptions about norms that may drive overuse of some tests. Previous studies found SCF to be effective in some areas of overuse (for example, in reducing inappropriate prescribing of antibiotics for acute upper respiratory infections 16,17 ). Potential advantages of SCF over other interventions include allowing ordering providers to maintain autonomy over individual decision making, which is salient in areas of practice with high clinical uncertainty, 18 and offering the potential for broad adoption of electronic medical record(EMR)-basedautomateddashboards tofacilitateautomated personalized feedback.…”

Hot Off the Press: Please Stop, Prescribing – Antibiotics for Viral Acute Respiratory Infections

“…There is evidence both in the medical literature and in economic theory to support using a package of feedback, nudges, and peer comparisons to improve prescribing outcomes. This has been shown to reduce unnecessary antibiotic prescribing in primary care, and in one study of peer comparisons in outpatient clinics and doctor's offices, these improvements were sustained for at least 12 months after the interventions were completed …”