Perspective

Durable change in antibiotic prescribing requires long-term interventions

Inappropriate antibiotic prescribing rates increased 12 months after behavioral interventions stopped, 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 Infectious Disease News.

“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.”

Jason N. Doctor

Doctor and colleagues conducted a cluster randomized trial of three behavioral interventions to reduce inappropriate antibiotic prescribing: 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 for acute respiratory infections.

The study included 248 clinicians from 47 primary care practices.

The interventions lasted 18 months, and 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. During the study, two of the three interventions — accountable justification and peer comparison — significantly reduced inappropriate antibiotic prescribing at the end of the intervention period.

Twelve months after the intervention 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%. However, the rate of inappropriate antibiotic prescribing increased from 4.8% to 6.3% for the peer comparison intervention, 6.1% to 10.2% for the accountable justification intervention, and 7.4% to 8.8% for the suggested alternatives intervention.

Researchers suggested that long-term implementation of interventions would continue to reduce inappropriate prescribing.

“While at least some interventions have staying power, effects are diminished to a degree when social motivations are removed,” Doctor said. “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 study for all other authors’ relevant financial disclosures.

Inappropriate antibiotic prescribing rates increased 12 months after behavioral interventions stopped, 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 Infectious Disease News.

“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.”

Jason N. Doctor

Doctor and colleagues conducted a cluster randomized trial of three behavioral interventions to reduce inappropriate antibiotic prescribing: 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 for acute respiratory infections.

The study included 248 clinicians from 47 primary care practices.

The interventions lasted 18 months, and 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. During the study, two of the three interventions — accountable justification and peer comparison — significantly reduced inappropriate antibiotic prescribing at the end of the intervention period.

Twelve months after the intervention 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%. However, the rate of inappropriate antibiotic prescribing increased from 4.8% to 6.3% for the peer comparison intervention, 6.1% to 10.2% for the accountable justification intervention, and 7.4% to 8.8% for the suggested alternatives intervention.

Researchers suggested that long-term implementation of interventions would continue to reduce inappropriate prescribing.

“While at least some interventions have staying power, effects are diminished to a degree when social motivations are removed,” Doctor said. “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 study for all other authors’ relevant financial disclosures.

    Perspective
    C Buddy  Creech

    C Buddy Creech

    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 others data to guide clinical decisions. Over time, individual behaviors change to match the community.

    ,

    C. Buddy Creech

    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, there is ongoing sharpening of our clinical tools that must occur.

    • C Buddy Creech, MD MPH
    • Associate professor of pediatrics

    Disclosures: Disclosure: Creech reports no relevant financial disclosures.