Cognitive reflection and antibiotic prescribing for acute respiratory infections

Abstract

Background. Variation in clinical decision-making could be explained by clinicians' tendency to make 'snap-decisions' versus making more reflective decisions. One common clinical decision with unexplained variation is the prescription of antibiotics for acute respiratory infections (ARIs). Objective. We hypothesized that clinicians who tended toward greater cognitive reflection would be less likely to prescribe antibiotics for ARIs. Methods. The Cognitive Reflection Test (CRT) is a psychological test with three questions with intuitive but incorrect answers that respondents reach if they do not consider the question carefully. The CRT is scored from 0 to 3, representing the number of correct answers. A higher score indicates greater cognitive reflection. We administered the CRT to 187 clinicians in 50 primary care practices. From billing and electronic health record data, we calculated clinician-level antibiotic prescribing rates for ARIs in 3 categories: all ARIs, antibiotic-appropriate ARIs and non-antibiotic-appropriate ARIs. Results. A total of 57 clinicians (31%) scored 0 points on the CRT; 38 (20%) scored 1; 51 (27%) scored 2; and 41 (22%) scored 3. We found a roughly U-shaped association between cognitive reflection and antibiotic prescribing. The antibiotic prescribing rate for CRT scores of 0, 1, 2 and 3 for all ARIs (n = 37 080 visits) was 32%, 26%, 25% and 30% (P = 0.10); for antibiotic-appropriate ARIs (n = 11 220 visits) was 60%, 55%, 54% and 58% (P = 0.63); and for non-antibiotic-appropriate ARIs (n = 25 860 visits) was 21%, 17%, 13% and 18%, respectively (P = 0.03). Conclusions. In contrast to our hypothesis, there appears to be a 'sweet-spot' of cognitive reflection for antibiotic prescribing for non-antibiotic-appropriate ARIs. Differences in clinicians' cognitive reflection may be associated with other variations in care.

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

“…We administered the CRT to 57 clinicians and found a U-shaped relationship between clinicians at the lowest and highest CRT scores and higher antibiotic prescribing rates for respiratory infections. 95 We hypothesized that those with the lowest CRT scores tended to not consider problems carefully, and that those with the highest CRT scores may have overthought the clinical situation and worried about alternative diagnoses or potential complications.…”

Capsule Commentary on Klein et al., Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: a Mixed Methods Observational Study

“…Contextual, communication, and social factors have a role. [2][3][4][5] The importance of the association between the gists and antibiotic prescribing, because of low prevalence and weak strength of association, could be small relative to other factors. For example, in the main model, the Bwhy-not-take-a-riskĝ ist was associated with 28% increased odds of prescribing antibiotics, which only increases absolute antibiotic prescribing from, for example, 64% to 69%.…”