Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.
Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.
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“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.
In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.
The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.
The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.
The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.
The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.
The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.