Simple Approach Reduces Antibiotic Overprescription

Lara C. Pullen, PhD

January 30, 2014

Physicians who display poster-size letters stating their commitment to avoiding inappropriate prescription of antibiotics for acute respiratory infections (ARIs) are less likely to prescribe inappropriate antibiotics, according to a randomized clinical trial by Daniella Meeker, PhD, from RAND Corporation in Santa Monica, California, and colleagues, who present their results in an article published online January 27 in JAMA Internal Medicine.

The poster intervention is simple and low-cost, and its effect was as large as costlier, more intensive quality-improvement efforts.

The investigators evaluated the antibiotic prescription rates of physicians who signed and posted a letter in their examination rooms that stated their intention to avoid inappropriate antibiotic prescribing for ARIs. The approach is based on and supports the rational model of physician behavior. The authors also emphasize that the intervention engages the patient in the decision making and that this shared approach is critical for changing behavior.

The researchers conducted the study over the course of 12 weeks in 5 Los Angeles community clinics. There were 954 adults with ARI visits during the study: 449 patients were treated by clinicians assigned to the intervention arm and 505 patients were treated by clinicians randomly assigned to standard practice control. Both groups had both a baseline period and an intervention period.

The investigators report a 19.7% absolute reduction after the intervention in inappropriate antibiotic prescribing rate relative to the control group (P = .02). At baseline, the rate of antibiotic prescribing were similar between the intervention and control groups, at 43.5% and 42.8%, respectively. During the study, the rate dropped to 33.7% in the intervention group and climbed to 52.7% in the control group.

The results are consistent with those in other fields that have measured the effect of public commitments on behavior.

Although there was a significant decrease in inappropriate prescribing of antibiotics in the intervention group, the authors note that the rate remained high, with more than one-third of patients receiving antibiotics.

Typically, quality improvement is achieved through "audit with feedback" and "pay for performance." In contrast to these approaches, the poster is simple, low-cost, and scalable. The authors propose that the behavior change is the result of concern about peer disapproval and personal dedication to performing the behavior.

"We all bear responsibility to protect the public resource of antibiotic efficacy. We do need to continue critical, traditional antibiotic stewardship efforts, including education, restrictions, de-escalation, electronic reminders, etc. But new ideas, such as the simple and gentle public commitment concept Meeker and colleagues have developed, are needed to work in concert with traditional approaches to help us change the future state of antibiotic resistance," writes Brad Spellberg, MD of Harbor-University of California, Los Angeles, Medical Center, in an invited commentary.

Dr. Meeker is an employee of RAND Corporation, which was subcontracted for this study. Dr. Spellberg's institute has received funding from Pfizer, Abbott, and Cempra.

JAMA Intern Med. Published online January 27, 2014. Article abstract, Commentary extract


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