Exam-room posters declaring a clinician’s commitment to make appropriate antibiotics prescriptions may be a simple, low-cost approach to reducing inappropriate use of antibiotics for acute respiratory infections, according to a report published online Jan. 27 in JAMA Internal Medicine.
Compared with standard practice, the intervention reduced inappropriate prescribing by 20% but had no effect on appropriate prescribing of antibiotics among 11 physicians and three nurse practitioners treating acute respiratory infection at five outpatient primary care clinics. The improvement is comparable to that reported previously for more intensive and expensive interventions, said Daniella Meeker, Ph.D., of RAND Corp., Santa Monica, Calif., and her associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14191]).
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A simple intervention such as exam room posters, can remind physicians to make appropriate prescriptions for antibiotics, especially for acute respiratory infections.
If these results were extrapolated to the entire United States, the intervention "could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million annually on drug costs alone," the investigators noted.
"To encourage more judicious use of antibiotics, we designed an intervention that takes advantage of clinicians’ desire to be consistent with their pubic commitments," Dr. Meeker and her colleagues said. "We developed a ... behavioral ‘nudge’ in the form of a public commitment device: a poster-sized letter signed by clinicians and posted in their examination rooms indicating their commitment to reducing inappropriate antibiotic use for acute respiratory infections."
"Public commitment" is a psychological principle that holds that people are much more likely to follow a course of action if they and others have publicly stated that they will do so. It was hoped that an intervention that taps into existing internal motivations would be a more subtle and effective approach than external "reeducation" programs or heavy-handed penalties such as withholding reimbursement for writing too many prescriptions.
Other public commitment approaches have proved successful at increasing participation in recycling programs, getting hotel guests to reuse their towels, increasing donations to organizations serving the disabled, and raising voting rates in elections.
The intervention was a form letter written at the eighth-grade reading level in both English and Spanish and displayed on a poster hung in the exam room. The poster explained why antibiotics were not appropriate for many acute respiratory infections, and it emphasized the clinician’s commitment to follow guidelines for appropriate prescribing. The poster included a photo of the clinician and his or her signature on the letter.
For this study, the posters were used for 12-week periods by clinicians at five Los Angeles community clinics and were used in such a way that an entire 1-year flu cycle was covered. The medical records, including antibiotic prescriptions, were reviewed for all adults seen by the participating clinicians and diagnosed as having an acute respiratory infection for which antibiotics may or may not have been appropriate.
The 14 participating clinicians were randomly assigned to either the intervention (7 using the study condition) or to standard practice (7 control subjects). Eleven of these clinicians were women, and 3 were men. The mean age was 54 years, and the mean duration in practice was 18 years.
A total of 449 patients were included in the intervention group and 505 in the control group. Most (77%) were women, and their mean age was 48 years. Approximately 43% were uninsured.
Diagnoses included acute nasopharyngitis (12 visits), acute laryngitis without obstruction (4 visits), acute laryngopharyngitis (3 visits), acute bronchitis (125 visits), acute upper respiratory tract infections of other sites (10 visits) acute upper respiratory tract infections not otherwise specified (448 visits), bronchitis not specified as acute or chronic (181 visits), nonstreptococcal pharyngitis (161 visits), and influenza with other respiratory manifestations (10 visits).
At baseline, before the intervention was employed, the inappropriate-prescribing rate was 43.5% for clinicians in the intervention group and 42.8% for those in the control group, a nonsignificant difference. During the 12-week intervention period, the inappropriate-prescribing rate dropped to 33.7% for the intervention group but rose to 52.7% for the control group.
That represents a 19.7% reduction for the intervention group, compared with the control group, Dr. Meeker and her associates said.
There was no evidence that the participating clinicians may have undermined the intervention by shifting diagnosis codes away from those that don’t require antibiotics and toward those that might. Diagnostic codes did not change appreciably between baseline and intervention periods in either study group, the researchers said.
Moreover, the rate of appropriate antibiotic prescribing did not change during the intervention period, indicating that clinicians continued to prescribe antibiotics when they were indicated and only stopped prescribing them when they were truly unnecessary.