Behavioral interventions reduce inappropriate antibiotic prescription

1. Behavioral interventions, particular accountable justification and peer comparison, reduced inappropriate antibiotic prescription among primary care physicians to a greater extent than education and observation alone.

2. Rates of return visits were nearly identical between all intervention groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Antibiotic over-prescription increases unnecessary health care costs, and, perhaps more concerning, predisposes towards the emergence of drug resistant pathogens. While many physicians are aware of these issues, the rates of over-prescription, especially for respiratory tract infections, remains high. In this randomized controlled trial, educational modules and observation of primary care practices were combined randomly with three behavioral interventions (alternative suggestions, accountable justification, and peer comparisons) across a number of practices in Southern California and Massachusetts. Education and observation alone served as a control, and led to reduced rates of inappropriate antibiotic prescriptions. However, both peer comparison and accountable justification interventions, alone or in combination, reduced the rates even further. While prescription rates were significantly lower in the combined accountable justification and peer comparison group, the rate of return clinic visits was only modestly increased. The implementation of these physician-directed behavioral interventions was relatively unobtrusive, and demonstrated an efficient and cost-effective approach for lowering the rates of inappropriate antibiotic prescription. However, while the data is encouraging, the low number of practices per group (~4-7) and mediocre recruitment rate (70% of physicians approached) warrant further follow up on larger scale.

Click to read the study, published today in JAMA

Relevant Reading: Asymmetric paternalism to improve health behaviors

In-Depth [randomized controlled trial]: A total of 248 clinicians across 47 primary care practices in Southern California and Massachusetts were recruited for this 18 month study. After initial education, a baseline of inappropriate antibiotic prescription rates for certain respiratory tract illnesses was established during the first 9 months of the study. Each primary care practice was then randomly assigned to receive 0, 1, 2, or 3 behavioral interventions.

The “Suggested Alternatives” intervention displayed a pop-up window in the EHR when physicians prescribed inappropriate antibiotics. The “Accountable Justification” intervention required physicians to write a note when prescribing antibiotics in situations that did not necessarily warrant them. The “Peer Comparison” intervention sent a rank-ordered list of physicians at each practice sorted by their rates of inappropriate antibiotic prescription.

Among physicians in the control group (receiving 0 interventions), the rate of inappropriate antibiotic prescriptions dropped from 24.1% to 13.1% (-11% difference). “Accountable Justification” led to a further 7.0% reduction (95%CI -9.1 to -2.9%), while “Peer Comparison” decreased the rate an additional -5.0% (95%CI -6.9 to -1.6%). There was no statistically significant difference between the control and “Alternative Suggestions” intervention. In terms of safety, only “Accountable Justification” and “Peer Comparison” in combination had a higher rate of return visits (1.41%; 95%CI 1.06% to 1.85%) compared to the control group (0.43%; 95%CI 0.25% to 0.70%).

 

Image: PD

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