Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial

BMC Infect Dis. 2016 Aug 5;16:373. doi: 10.1186/s12879-016-1715-8.

Abstract

Background: Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.

Methods: Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.

Results: We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995).

Conclusions: We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.

Trial registration: ClinicalTrials.gov: NCT01454960 .

Keywords: Acute respiratory infections; Antibiotics; Behavioral economics; Clinical decision support; Social psychology.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Acute Disease
  • Adult
  • Anti-Bacterial Agents / therapeutic use*
  • Behavior*
  • Decision Making
  • Decision Support Systems, Clinical
  • Education, Medical, Continuing / methods*
  • Female
  • Humans
  • Inappropriate Prescribing / prevention & control*
  • Inappropriate Prescribing / statistics & numerical data
  • Interprofessional Relations
  • Male
  • Middle Aged
  • Pharyngitis / drug therapy
  • Physicians, Primary Care* / education
  • Physicians, Primary Care* / psychology
  • Physicians, Primary Care* / standards
  • Pilot Projects
  • Practice Patterns, Physicians'* / standards
  • Practice Patterns, Physicians'* / statistics & numerical data
  • Prescriptions / standards
  • Prescriptions / statistics & numerical data
  • Respiratory Tract Infections / drug therapy
  • Sinusitis / drug therapy

Substances

  • Anti-Bacterial Agents

Associated data

  • ClinicalTrials.gov/NCT01454960