User login
Exam-room posters declaring a clinician’s commitment to make appropriate antibiotics prescriptions may be a simple, low-cost approach to reducing inappropriate use of antibiotics for acute respiratory infections, according to a report published online Jan. 27 in JAMA Internal Medicine.
Compared with standard practice, the intervention reduced inappropriate prescribing by 20% but had no effect on appropriate prescribing of antibiotics among 11 physicians and three nurse practitioners treating acute respiratory infection at five outpatient primary care clinics. The improvement is comparable to that reported previously for more intensive and expensive interventions, said Daniella Meeker, Ph.D., of RAND Corp., Santa Monica, Calif., and her associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14191]).
If these results were extrapolated to the entire United States, the intervention "could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million annually on drug costs alone," the investigators noted.
"To encourage more judicious use of antibiotics, we designed an intervention that takes advantage of clinicians’ desire to be consistent with their pubic commitments," Dr. Meeker and her colleagues said. "We developed a ... behavioral ‘nudge’ in the form of a public commitment device: a poster-sized letter signed by clinicians and posted in their examination rooms indicating their commitment to reducing inappropriate antibiotic use for acute respiratory infections."
"Public commitment" is a psychological principle that holds that people are much more likely to follow a course of action if they and others have publicly stated that they will do so. It was hoped that an intervention that taps into existing internal motivations would be a more subtle and effective approach than external "reeducation" programs or heavy-handed penalties such as withholding reimbursement for writing too many prescriptions.
Other public commitment approaches have proved successful at increasing participation in recycling programs, getting hotel guests to reuse their towels, increasing donations to organizations serving the disabled, and raising voting rates in elections.
The intervention was a form letter written at the eighth-grade reading level in both English and Spanish and displayed on a poster hung in the exam room. The poster explained why antibiotics were not appropriate for many acute respiratory infections, and it emphasized the clinician’s commitment to follow guidelines for appropriate prescribing. The poster included a photo of the clinician and his or her signature on the letter.
For this study, the posters were used for 12-week periods by clinicians at five Los Angeles community clinics and were used in such a way that an entire 1-year flu cycle was covered. The medical records, including antibiotic prescriptions, were reviewed for all adults seen by the participating clinicians and diagnosed as having an acute respiratory infection for which antibiotics may or may not have been appropriate.
The 14 participating clinicians were randomly assigned to either the intervention (7 using the study condition) or to standard practice (7 control subjects). Eleven of these clinicians were women, and 3 were men. The mean age was 54 years, and the mean duration in practice was 18 years.
A total of 449 patients were included in the intervention group and 505 in the control group. Most (77%) were women, and their mean age was 48 years. Approximately 43% were uninsured.
Diagnoses included acute nasopharyngitis (12 visits), acute laryngitis without obstruction (4 visits), acute laryngopharyngitis (3 visits), acute bronchitis (125 visits), acute upper respiratory tract infections of other sites (10 visits) acute upper respiratory tract infections not otherwise specified (448 visits), bronchitis not specified as acute or chronic (181 visits), nonstreptococcal pharyngitis (161 visits), and influenza with other respiratory manifestations (10 visits).
At baseline, before the intervention was employed, the inappropriate-prescribing rate was 43.5% for clinicians in the intervention group and 42.8% for those in the control group, a nonsignificant difference. During the 12-week intervention period, the inappropriate-prescribing rate dropped to 33.7% for the intervention group but rose to 52.7% for the control group.
That represents a 19.7% reduction for the intervention group, compared with the control group, Dr. Meeker and her associates said.
There was no evidence that the participating clinicians may have undermined the intervention by shifting diagnosis codes away from those that don’t require antibiotics and toward those that might. Diagnostic codes did not change appreciably between baseline and intervention periods in either study group, the researchers said.
Moreover, the rate of appropriate antibiotic prescribing did not change during the intervention period, indicating that clinicians continued to prescribe antibiotics when they were indicated and only stopped prescribing them when they were truly unnecessary.
The intervention, based on a psychological principle, was more effective at curtailing inappropriate prescription of antibiotics than are many others currently in use. Those others typically are based on a model holding that clinicians will change their behavior simply because it makes rational sense to do so, and they use techniques such as education, awareness training, electronic alerts or reminders, and financial incentives, the researchers explained.
"[Our] findings support an alternative model suggesting that clinicians are influenced by interpersonal factors within the context of patient care – in particular, a desire to remain consistent with a prior public commitment," Dr. Meeker and her associates said.
They added that their study was limited because it covered a relatively small geographic area, involved a small number of clinicians, and was of short duration. Moreover, even though the intervention succeeded in reducing inappropriate prescribing significantly, the rate of inappropriate prescribing still remained high among the study participants.
The National Institutes of Health and the National Institute on Aging funded the study. Dr. Meeker and her associates reported no relevant financial conflicts of interest.
Dr. Meeker and her colleagues have developed a novel intervention "based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescription," and it required no complex algorithms, no special technology, no infrastructure, and no enforcement, observed Dr. Brad Spellberg.
"Rather than direct confrontation with the force of education or nagging, they sought a gentler ‘nudging’ approach that worked harmoniously with the underlying psychology of both patient and clinician," he noted.
It remains to be seen whether "this gentle nudge approach" can be generalized to other clinical practices across the country, he added, and whether its effectiveness will be sustained over the long term.
Dr. Spellberg is in the division of general internal medicine at Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute in Torrance, Calif. His work is supported by the National Institute of Allergy and Infectious Diseases, and he reported ties to Abbott, Adenium, aRigen, Cardeas, Cempra, GlaxoSmithKline, Meiji, Novan, Pfizer, and Synthetic Biologics. These comments were taken from his invited commentary accompanying Dr. Meeker’s report (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14019]).
Dr. Meeker and her colleagues have developed a novel intervention "based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescription," and it required no complex algorithms, no special technology, no infrastructure, and no enforcement, observed Dr. Brad Spellberg.
"Rather than direct confrontation with the force of education or nagging, they sought a gentler ‘nudging’ approach that worked harmoniously with the underlying psychology of both patient and clinician," he noted.
It remains to be seen whether "this gentle nudge approach" can be generalized to other clinical practices across the country, he added, and whether its effectiveness will be sustained over the long term.
Dr. Spellberg is in the division of general internal medicine at Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute in Torrance, Calif. His work is supported by the National Institute of Allergy and Infectious Diseases, and he reported ties to Abbott, Adenium, aRigen, Cardeas, Cempra, GlaxoSmithKline, Meiji, Novan, Pfizer, and Synthetic Biologics. These comments were taken from his invited commentary accompanying Dr. Meeker’s report (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14019]).
Dr. Meeker and her colleagues have developed a novel intervention "based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescription," and it required no complex algorithms, no special technology, no infrastructure, and no enforcement, observed Dr. Brad Spellberg.
"Rather than direct confrontation with the force of education or nagging, they sought a gentler ‘nudging’ approach that worked harmoniously with the underlying psychology of both patient and clinician," he noted.
It remains to be seen whether "this gentle nudge approach" can be generalized to other clinical practices across the country, he added, and whether its effectiveness will be sustained over the long term.
Dr. Spellberg is in the division of general internal medicine at Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute in Torrance, Calif. His work is supported by the National Institute of Allergy and Infectious Diseases, and he reported ties to Abbott, Adenium, aRigen, Cardeas, Cempra, GlaxoSmithKline, Meiji, Novan, Pfizer, and Synthetic Biologics. These comments were taken from his invited commentary accompanying Dr. Meeker’s report (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14019]).
Exam-room posters declaring a clinician’s commitment to make appropriate antibiotics prescriptions may be a simple, low-cost approach to reducing inappropriate use of antibiotics for acute respiratory infections, according to a report published online Jan. 27 in JAMA Internal Medicine.
Compared with standard practice, the intervention reduced inappropriate prescribing by 20% but had no effect on appropriate prescribing of antibiotics among 11 physicians and three nurse practitioners treating acute respiratory infection at five outpatient primary care clinics. The improvement is comparable to that reported previously for more intensive and expensive interventions, said Daniella Meeker, Ph.D., of RAND Corp., Santa Monica, Calif., and her associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14191]).
If these results were extrapolated to the entire United States, the intervention "could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million annually on drug costs alone," the investigators noted.
"To encourage more judicious use of antibiotics, we designed an intervention that takes advantage of clinicians’ desire to be consistent with their pubic commitments," Dr. Meeker and her colleagues said. "We developed a ... behavioral ‘nudge’ in the form of a public commitment device: a poster-sized letter signed by clinicians and posted in their examination rooms indicating their commitment to reducing inappropriate antibiotic use for acute respiratory infections."
"Public commitment" is a psychological principle that holds that people are much more likely to follow a course of action if they and others have publicly stated that they will do so. It was hoped that an intervention that taps into existing internal motivations would be a more subtle and effective approach than external "reeducation" programs or heavy-handed penalties such as withholding reimbursement for writing too many prescriptions.
Other public commitment approaches have proved successful at increasing participation in recycling programs, getting hotel guests to reuse their towels, increasing donations to organizations serving the disabled, and raising voting rates in elections.
The intervention was a form letter written at the eighth-grade reading level in both English and Spanish and displayed on a poster hung in the exam room. The poster explained why antibiotics were not appropriate for many acute respiratory infections, and it emphasized the clinician’s commitment to follow guidelines for appropriate prescribing. The poster included a photo of the clinician and his or her signature on the letter.
For this study, the posters were used for 12-week periods by clinicians at five Los Angeles community clinics and were used in such a way that an entire 1-year flu cycle was covered. The medical records, including antibiotic prescriptions, were reviewed for all adults seen by the participating clinicians and diagnosed as having an acute respiratory infection for which antibiotics may or may not have been appropriate.
The 14 participating clinicians were randomly assigned to either the intervention (7 using the study condition) or to standard practice (7 control subjects). Eleven of these clinicians were women, and 3 were men. The mean age was 54 years, and the mean duration in practice was 18 years.
A total of 449 patients were included in the intervention group and 505 in the control group. Most (77%) were women, and their mean age was 48 years. Approximately 43% were uninsured.
Diagnoses included acute nasopharyngitis (12 visits), acute laryngitis without obstruction (4 visits), acute laryngopharyngitis (3 visits), acute bronchitis (125 visits), acute upper respiratory tract infections of other sites (10 visits) acute upper respiratory tract infections not otherwise specified (448 visits), bronchitis not specified as acute or chronic (181 visits), nonstreptococcal pharyngitis (161 visits), and influenza with other respiratory manifestations (10 visits).
At baseline, before the intervention was employed, the inappropriate-prescribing rate was 43.5% for clinicians in the intervention group and 42.8% for those in the control group, a nonsignificant difference. During the 12-week intervention period, the inappropriate-prescribing rate dropped to 33.7% for the intervention group but rose to 52.7% for the control group.
That represents a 19.7% reduction for the intervention group, compared with the control group, Dr. Meeker and her associates said.
There was no evidence that the participating clinicians may have undermined the intervention by shifting diagnosis codes away from those that don’t require antibiotics and toward those that might. Diagnostic codes did not change appreciably between baseline and intervention periods in either study group, the researchers said.
Moreover, the rate of appropriate antibiotic prescribing did not change during the intervention period, indicating that clinicians continued to prescribe antibiotics when they were indicated and only stopped prescribing them when they were truly unnecessary.
The intervention, based on a psychological principle, was more effective at curtailing inappropriate prescription of antibiotics than are many others currently in use. Those others typically are based on a model holding that clinicians will change their behavior simply because it makes rational sense to do so, and they use techniques such as education, awareness training, electronic alerts or reminders, and financial incentives, the researchers explained.
"[Our] findings support an alternative model suggesting that clinicians are influenced by interpersonal factors within the context of patient care – in particular, a desire to remain consistent with a prior public commitment," Dr. Meeker and her associates said.
They added that their study was limited because it covered a relatively small geographic area, involved a small number of clinicians, and was of short duration. Moreover, even though the intervention succeeded in reducing inappropriate prescribing significantly, the rate of inappropriate prescribing still remained high among the study participants.
The National Institutes of Health and the National Institute on Aging funded the study. Dr. Meeker and her associates reported no relevant financial conflicts of interest.
Exam-room posters declaring a clinician’s commitment to make appropriate antibiotics prescriptions may be a simple, low-cost approach to reducing inappropriate use of antibiotics for acute respiratory infections, according to a report published online Jan. 27 in JAMA Internal Medicine.
Compared with standard practice, the intervention reduced inappropriate prescribing by 20% but had no effect on appropriate prescribing of antibiotics among 11 physicians and three nurse practitioners treating acute respiratory infection at five outpatient primary care clinics. The improvement is comparable to that reported previously for more intensive and expensive interventions, said Daniella Meeker, Ph.D., of RAND Corp., Santa Monica, Calif., and her associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed.2013.14191]).
If these results were extrapolated to the entire United States, the intervention "could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million annually on drug costs alone," the investigators noted.
"To encourage more judicious use of antibiotics, we designed an intervention that takes advantage of clinicians’ desire to be consistent with their pubic commitments," Dr. Meeker and her colleagues said. "We developed a ... behavioral ‘nudge’ in the form of a public commitment device: a poster-sized letter signed by clinicians and posted in their examination rooms indicating their commitment to reducing inappropriate antibiotic use for acute respiratory infections."
"Public commitment" is a psychological principle that holds that people are much more likely to follow a course of action if they and others have publicly stated that they will do so. It was hoped that an intervention that taps into existing internal motivations would be a more subtle and effective approach than external "reeducation" programs or heavy-handed penalties such as withholding reimbursement for writing too many prescriptions.
Other public commitment approaches have proved successful at increasing participation in recycling programs, getting hotel guests to reuse their towels, increasing donations to organizations serving the disabled, and raising voting rates in elections.
The intervention was a form letter written at the eighth-grade reading level in both English and Spanish and displayed on a poster hung in the exam room. The poster explained why antibiotics were not appropriate for many acute respiratory infections, and it emphasized the clinician’s commitment to follow guidelines for appropriate prescribing. The poster included a photo of the clinician and his or her signature on the letter.
For this study, the posters were used for 12-week periods by clinicians at five Los Angeles community clinics and were used in such a way that an entire 1-year flu cycle was covered. The medical records, including antibiotic prescriptions, were reviewed for all adults seen by the participating clinicians and diagnosed as having an acute respiratory infection for which antibiotics may or may not have been appropriate.
The 14 participating clinicians were randomly assigned to either the intervention (7 using the study condition) or to standard practice (7 control subjects). Eleven of these clinicians were women, and 3 were men. The mean age was 54 years, and the mean duration in practice was 18 years.
A total of 449 patients were included in the intervention group and 505 in the control group. Most (77%) were women, and their mean age was 48 years. Approximately 43% were uninsured.
Diagnoses included acute nasopharyngitis (12 visits), acute laryngitis without obstruction (4 visits), acute laryngopharyngitis (3 visits), acute bronchitis (125 visits), acute upper respiratory tract infections of other sites (10 visits) acute upper respiratory tract infections not otherwise specified (448 visits), bronchitis not specified as acute or chronic (181 visits), nonstreptococcal pharyngitis (161 visits), and influenza with other respiratory manifestations (10 visits).
At baseline, before the intervention was employed, the inappropriate-prescribing rate was 43.5% for clinicians in the intervention group and 42.8% for those in the control group, a nonsignificant difference. During the 12-week intervention period, the inappropriate-prescribing rate dropped to 33.7% for the intervention group but rose to 52.7% for the control group.
That represents a 19.7% reduction for the intervention group, compared with the control group, Dr. Meeker and her associates said.
There was no evidence that the participating clinicians may have undermined the intervention by shifting diagnosis codes away from those that don’t require antibiotics and toward those that might. Diagnostic codes did not change appreciably between baseline and intervention periods in either study group, the researchers said.
Moreover, the rate of appropriate antibiotic prescribing did not change during the intervention period, indicating that clinicians continued to prescribe antibiotics when they were indicated and only stopped prescribing them when they were truly unnecessary.
The intervention, based on a psychological principle, was more effective at curtailing inappropriate prescription of antibiotics than are many others currently in use. Those others typically are based on a model holding that clinicians will change their behavior simply because it makes rational sense to do so, and they use techniques such as education, awareness training, electronic alerts or reminders, and financial incentives, the researchers explained.
"[Our] findings support an alternative model suggesting that clinicians are influenced by interpersonal factors within the context of patient care – in particular, a desire to remain consistent with a prior public commitment," Dr. Meeker and her associates said.
They added that their study was limited because it covered a relatively small geographic area, involved a small number of clinicians, and was of short duration. Moreover, even though the intervention succeeded in reducing inappropriate prescribing significantly, the rate of inappropriate prescribing still remained high among the study participants.
The National Institutes of Health and the National Institute on Aging funded the study. Dr. Meeker and her associates reported no relevant financial conflicts of interest.
FROM JAMA INTERNAL MEDICINE
Major finding: During the 12-week intervention period, the inappropriate prescribing rate dropped from 43.5% to 33.7% for the intervention group but rose from 42.8% to 52.7% for the control group, which represents a 19.7% relative reduction with the intervention.
Data source: A randomized clinical trial involving 14 clinicians and 954 of their adult patients who presented with acute respiratory infection during a 1-year period, in which half the clinicians used an intervention to help decrease the inappropriate prescribing of antibiotics.
Disclosures: This study was funded by the National Institutes of Health and the National Institute on Aging. Dr. Meeker and her associates reported no relevant financial conflicts of interest.
