PerspectiveIn the Journals

Signed ‘commitment letters’ lowered inappropriate antibiotic prescriptions

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January 30, 2014

A simple reminder in the form of signed letters displayed in examination rooms that emphasized clinician commitment to antimicrobial stewardship reduced inappropriate prescribing for acute respiratory infections by 20% and could potentially save more than $70 million a year in drug costs in the United States, researchers reported.

“Most quality improvement efforts have used audits or pay-for-performance incentives to try to change what providers do, but they ignore social influences that affect all people, including physicians,” Jason Doctor, PhD, of the Schaeffer Center for Health Policy and Economics at the University of Southern California and associate professor of clinical pharmacy and pharmaceutical economics and policy at the USC School of Pharmacy, said in a press release. “Our study is the first to apply the principles of commitment and consistency to prescribing behavior and finds a simple, low-cost intervention that shows great promise in reducing inappropriate antibiotic prescription.”

Doctor and colleagues evaluated an intervention that consisted of displaying poster-sized “commitment letters” in examination rooms for 12 weeks during peak cold and influenza season. The letters featured photographs and signatures of clinicians who stated their commitment to avoid inappropriate antibiotic prescribing for acute respiratory infections.

Fourteen clinicians from five outpatient primary care clinics were randomly assigned to the intervention or standard practice. A total of 954 adult patients with acute respiratory infections were treated throughout the study period — 449 by clinicians participating in the intervention and 505 by clinicians in the control group.

Inappropriate antibiotic prescribing rates at baseline were 42.8% in the intervention group and 43.5% in the control group. Inappropriate prescribing for acute respiratory infections increased to 52.7% among clinicians who did not post a commitment letter, but decreased to 33.7% among clinicians who did — a reduction of almost 10%. Compared with standard practice, use of commitment letters led to a 19.7% reduction in inappropriate antibiotic prescribing (P=.02).

According to the researchers, rates of appropriate antibiotic prescriptions for acute respiratory infections did not diminish with time.

The researchers calculated that if the intervention were applied nationally it could eliminate 2.6 million unnecessary antibiotic prescriptions and save up to $70.4 million in drug costs each year.

According to study researcher Daniella Meeker, PhD, systems engineer and an associate information scientist at the Rand Corporation, posters in examination rooms are commonly used as reminders of clinical guidelines. However, this may be the first time that posters included clinicians’ signatures, photographs and written commitments to better patient care. The improvements in antibiotic prescribing were greater than the researchers would have expected from studies of past interventions that used posters, she said.

Daniella Meeker, PhD 

Daniella Meeker

“This is a new way to approach improvement in care quality — one that engages providers in personal and public commitments to achieve better patient care,” Meeker told Infectious Disease News. “Given concerns of increased antibiotic resistance, improvements in antibiotic prescribing practice is a particularly important application.” – John Schoen

Disclosure: Meeker is an employee of the Rand Corporation. The study was funded by the NIH. See the study for a full list of financial disclosures.

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James M. Hughes

James M. Hughes

Antimicrobial resistance is a complex, urgent global threat of concern to clinical and public health practitioners and increasingly to the public. The problem requires a multifaceted strategy to confront it. Antimicrobial stewardship efforts to encourage judicious use are one important component of the strategy. Innovative evidence-based approaches are needed to encourage judicious prescribing and minimize inappropriate use. The carefully done study by Meeker and colleagues focused on evaluation of a novel behavioral intervention in primary care clinics in Los Angeles that treat adults with acute respiratory infections. The study provides important evidence that giving a “nudge” to primary care providers by posting “commitment letter” posters in English and Spanish in examination rooms with a signature and photograph of the providers was associated with a reduction in inappropriate prescribing rates compared with a control group of providers not displaying posters. Providers in the intervention group reduced their inappropriate prescribing rate by approximately 10% compared with the baseline period, while those in the control group increased their inappropriate rate by 10% during the 12-week intervention period during influenza season. These results support the potential value of this simple, low-cost behavioral approach as a component of stewardship efforts in outpatient settings. Further larger studies targeting acute respiratory and other common infections in additional geographic locations are merited to assess generalizability and sustainability of these results.

James M. Hughes, MD, FIDSA
Infectious Disease News Editorial Board member
Past president, IDSA

Disclosure: Hughes reports no relevant financial disclosures.