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Vital Signs Blog

Blog: To curb inappropriate antibiotic prescribing, researchers try social psych

If you want physicians to stop overprescribing antibiotics, don't just give them guidelines—add a little social manipulation. At least that's what researchers comparing the effectiveness of various interventions for inappropriate outpatient prescribing found in a JAMA study published Tuesday.

Most antibiotics in the U.S. are prescribed in outpatient settings for acute respiratory tract infections, but about half of those infections cannot be treated with antibiotics. Such inappropriate prescribing has been shown to contribute to increased antimicrobial resistance, which the U.S. Centers for Disease Control and Prevention warn leads to at least 23,000 deaths every year. Efforts by public health, quality and provider organizations to curb such inappropriate prescribing through guidance, order-entry prompts and stewardship programs have yielded some improvement but the problem remains.

A study published in the Feb. 9 JAMA found that adding a social element to common behavioral nudges led to a greater reduction in overprescribing rates among physicians than guidance alone, without restricting their treatment decisions.

In the randomized clinical trial conducted in 47 primary-care practices in Boston and Los Angeles, researchers assigned 248 physicians to receive, for 18 months, one or more of the following interventions when they prescribed antibiotics for acute respiratory infections:

  • "Suggested alternatives,” an electronic health-record-based intervention which offered several options to antibiotic treatment, along with a notation that antibiotics were not indicated for that diagnosis
  • "Accountable justification," which prompted the physician to submit a free-text response justifying his or her decision in the EHR, which the clinician was told would be seen in the record as an “antibiotic justification note” (or would appear as a “no justification given” note if the provider declined to enter one)
  • "Peer comparison," an e-mail-based intervention that ranked physicians participating in the trial in each region, showing the highest to lowest rates of inappropriate antibiotic prescribing, and sent clinicians weekly e-mails telling them whether they were a “top performer” (i.e., demonstrating low rates of inappropriate prescribing)
  • A control group with no interventions


  • All participating physicians completed an online antibiotic education module covering diagnosis and treatment guidelines before the start of the trial, and all were compensated equally for their participation.

    At the end of the trial, physicians in all the intervention groups had reduced their rates of inappropriate antibiotic prescribing for acute respiratory tract infections. Physicians in the “suggested alternatives” intervention lowered their inappropriate prescription rates from 22.1% to 6.1%. Those in the “accountable justification” group lowered their rates from 23.2% to 5.2%, while those in the “peer comparison” group lowered their inappropriate prescribing rates from 19.9% to 3.7%. Physicians in the control group also lowered overprescribing rates, from 24.1% to 13.1%. But only the interventions with a social element—peer comparison and accountable justification—saw statistically significant reductions.

    The study's authors said that adding social nudges may have boosted the effectiveness of those two interventions, noting that the peer-comparison design fared well compared to audit-and-feedback studies, which compare performance to an average, rather than to top performers. The authors also said that prior studies using EHR justification prompts without public accountability showed little to no effect on physician behavior.

    A growing number of hospitals and inpatient care facilities are undertaking antibiotic stewardship programs, but smaller hospitals and ambulatory care facilities, which account for the majority of settings in which antibiotics are prescribed, often lack the dedicated staff or resources to implement such stewardship plans.

    In an accompanying editorial to the JAMA study, Dr. Jeffrey Gerber of the Children's Hospital of Philadelphia said that the study results were promising and could address that gap. "The interventions were simple, grounded in behavioral theory, and targeted prescribing at the point of care,” Gerber wrote. “Most importantly, this approach should easily translate across a variety of electronic health-record platforms, and might serve as the foundation of outpatient antimicrobial stewardship."






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