June 05, 2017
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Q&A: Physician prescribing behavior impacts drug resistance

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The CDC estimates that approximately 2 million Americans become infected with antibiotic-resistant bacteria, resulting in 23,000 deaths each year. Prior research has shown that a significant number of doctors overprescribe antibiotics, thus contributing to the problem of drug resistance.

To explain the problems that contribute to drug-resistance, and how physicians can improve their prescribing habits and antibiotic stewardship, Infectious Disease News spoke with Barbara Jones, MD, assistant professor of internal medicine at University of Utah Health and pulmonologist at the Veterans Affairs Salt Lake City Health Care System. – by Savannah Demko

Photo of Barbara Jones
Barbara Jones

What are the underlying problems contributing to antibiotic resistance?

Bacteria are constantly mutating with every cycle of generation. Some of these mutations give the bacteria resistance to standard antibiotics. If we are exposing these bacteria excessively to standard antibiotics, those bacteria that are resistant are selected. In other words, the constant exposure of bacteria to standard antibiotics in our environment sets up “selection pressure,” a scenario where more resistant bacteria emerge than bacteria that are susceptible to those antibiotics.

Can you discuss how historical, cultural and local attitudes factor into physician prescribing behaviors?

Doctors are very responsive to cultural and social norms of medicine. We want to practice the standard of care, and that often means that we look to other physicians — especially those in our immediate environment and those who we trained with or under — to adopt our practice styles. These styles can become habits, because the busier we are, the more we rely upon intuition and emotional cues to make decisions. When we become very busy, it is hard not to get into practice ruts, where we just do the same thing for one particular problem over and over again, simply because that’s how it’s always been done, that’s how our colleagues do it or that’s how we were trained to do it.

But while this explains why practice styles can emerge that can be so different across settings, I also think that the recognition of our susceptibility to cultural and social norms can be leveraged for change. Our study from the Annals of Internal Medicine demonstrated that physicians vary widely in their antibiotic prescribing — the top prescribing doctors gave antibiotic more than 95% of the time, whereas the lowest prescribing doctors gave antibiotics to less than 40% of their patients — and we found this variation even within the same clinic. To me, this means that there is potential for change, because high-prescribing physicians don’t have to go far — across the hallway, in fact — to learn from physicians who are prescribing more judiciously. For very good reasons, our culture loves antibiotics. Every doctor has been witness to how they have saved lives.

What are examples of effective interventions for improving physician attitudes toward antibiotic prescribing?

The most effective strategies so far have been:

  • audit-and-feedback strategies;
  • academic detailing (community outreach by clinical experts that educate providers, staff, and patients about the appropriate use of antibiotics);
  • provider-focused public commitments to reduce inappropriate antibiotic use, and delayed antibiotic prescriptions; and
  • clinical decision support systems (CDSS) that help physicians efficiently prescribe antibiotics more judiciously, or in the words of behavioral economics, “make it easier to do the right thing."

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I’m a big fan of audit-and-feedback and clinical decision support. Showing physicians their data, through audit-and-feedback strategies, seems to be a powerful influence on behavior. This is a relatively new concept in medicine – before the advent of electronic health records, there wasn’t an efficient way for us to be able to review and reflect on our practice from a “30,000-foot view.”

Regarding clinical decision support, supporting physicians by integrating interventions into their workflow seems to be quite important. Primary care physicians are busy people, and often the reason that we reach for prescriptions is that it can take us more time to go through the education that some patients need about antibiotics — so the most successful interventions are those that don’t take more time, or even save them time. The Veterans Affairs Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation in Salt Lake City (VA SLC IDEAS) is currently collaborating with the University of Utah under support from a grant from the CDC to test the effectiveness of these strategies across adult and pediatric settings.

CMS and The Joint Commission are now requiring antibiotic stewardship programs in all U.S. hospitals and critical access hospitals. How will this impact antibiotic prescribing?

I am really hopeful that this requirement will give hospitals the structure they need to start collecting reliable, relevant data that they can share with their doctors about prescribing. One of the core elements of antibiotic stewardship is the tracking and reporting of prescribing patterns, and — very importantly — feedback to the physicians about these patterns. As I said earlier, it is actually quite new to medicine for physicians to be able to make reviews of their practice like this, and the electronic health record has really made timely, accurate feedback possible. The challenge is in making sure that the data the doctors are receiving is accurate and trustworthy. This is critically important to feedback working to improve care: doctors must be able to trust the data.

What is the take-home message for clinicians regarding antibiotic overprescribing?

If there is one point I would make to clinicians it is that the variation in prescribing that we see at the physician level means that we are the source of the problem of overprescribing and that means that we are also the solution. Often, physicians feel that patients have expectations of an antibiotic prescription, and because we are sensitive to patient satisfaction, we may feel that we must meet those expectations. But most patients are following the advice of their physicians — and we have an opportunity and responsibility to educate our patients about the risks of antibiotic overuse, and reserve antibiotics for the patients who really need them. With doctors leading this movement, I think we really can change behavior.

Reference:

Jones BE, et al. Ann Intern Med. 2015;doi:10.7326/M14-1933.

Disclosures: Jones reports support from VA Health Services Career Development Award, the VA SLC IDEAS Center of Innovation and the CDC. The views expressed do not necessarily represent those of the VA or the CDC.