Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2014 Mar;174(3):425-31.
doi: 10.1001/jamainternmed.2013.14191.

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial

Daniella Meeker  1 , Tara K Knight  2 , Mark W Friedberg  3 , Jeffrey A Linder  4 , Noah J Goldstein  5 , Craig R Fox  5 , Alan Rothfeld  6 , Guillermo Diaz  7 , Jason N Doctor  2
Affiliations
Randomized Controlled Trial

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial

Daniella Meeker et al. JAMA Intern Med. 2014 Mar.

Abstract

Importance: "Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice.

Objective: To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs).

Design, setting, and participants: Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention).

Interventions: The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs.

Main outcomes and measures: Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status.

Results: Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time.

Conclusions and relevance: Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.

Trial registration: clinicaltrials.gov identifier: NCT01767064.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Drs Meeker and Friedberg are employees of RAND Corporation, which was subcontracted for this study with funds from grant RC4 AG039115. Dr Rothfeld is an employee of COPE Health Solutions, which was subcontracted for this study with funds from grant RC4 AG039115. At the time of this research, Dr Diaz was employed by QueensCare Family Clinics, and his work on this research was supported by a subcontract between QueensCare Family Clinics and COPE Health Solutions, which was subcontracted for this study with funds from grant RC4 AG039115.

Figures

Figure
Figure. Flow Diagram
A total of 14 clinicians completed the study, treating 954 patients.
See this image and copyright information in PMC

Comment in

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Allison ST, Messick DM. The feature positive effect, attitude strength, and degree of perceived consensus. Pers Soc Psychol Bull. 1988;14:231–241. - PubMed
    1. Cialdini RB, Bassett R, Cacioppo JT, Miller JA. Low-ball procedure for producing compliance: commitment then cost. J Pers Soc Psychol. 1978;36:463–476.
    1. Cioffi D, Garner R. On doing the decision: effects of active versus passive choice on commitment and self-perception. Pers Soc Psych Bull. 1996;22:133–144.
    1. Deutsch M, Gerard HB. A study of normative and informative social influences upon individual judgment. J Abnorm Soc Psychol. 1955;51:629–636. - PubMed
    1. Tedeschi J. Impression Management: Theory and Social Psychological Research. New York, NY: Academic Press; 1981.

Publication types

Substances

Associated data