Two simple behavioral interventions decreased the rate of unnecessary antibiotic prescriptions for acute respiratory tract infections, according to a recent study published in the Journal of the American Medical Association (JAMA) co-authored by Northwestern Medicine investigator Stephen Persell, MD, MPH.
Acute respiratory tract infections like bronchitis and the common cold are usually caused by viruses – not bacteria – so antibiotics won’t treat them. Nonetheless, research suggests that about half of the millions of antibiotic prescriptions in the United States every year are written for infections they won’t improve.
“The reason doctors don’t follow guidelines about antibiotic prescribing for upper respiratory infections is not because they don’t know the science,” said Dr. Persell, associate professor of Medicine in the Division of General Internal Medicine and Geriatrics. “There are other reasons: perceived patient demand, not knowing how to approach a patient with this expectation, overestimated fear of missing pneumonia and having a bad clinical outcome. Even fatigue may drive this to a degree.”
The repercussions of overusing antibiotics are significant. Patients are subjected to the adverse effects of the medicine with little chance of benefit, and overuse promotes spread of antibiotic-resistant bacteria that give rise to difficult-to-treat infections.
In the trial, 248 clinicians from 49 primary care practices in Boston and Los Angeles were randomized to receive interventions to change prescribing behavior. The study analyzed visits with patients diagnosed with antibiotic-inappropriate acute respiratory tract infections, but excluded patients who also had other chronic conditions.
“It’s the combination of a relatively healthy patient and a very benign diagnosis that suggests antibiotics are not needed,” explained Dr. Persell, who is also director of Northwestern’s Center for Primary Care Innovation.
The investigators tested three interventions: In one, clinicians received messages within patients’ electronic health records suggesting alternatives to antibiotics. In the second intervention, clinicians were required to enter justifications for prescribing antibiotics into patients’ records. In the third intervention, clinicians received emails comparing their antibiotic prescribing rates with those of “top performers,” who had the lowest rates of inappropriate prescribing.
“We tried to combat the non-rationale factors potentially making doctors do the wrong thing with nudges that encourage them to the do the right thing,” Dr. Persell said. “We relied on insights from social psychology.”
After a period of 18 months, two of the interventions – accountable justification and peer comparison – resulted in lower rates of unnecessary antibiotic prescribing. The third – suggested alternatives – did not result in a statistically significant change.
“Now we know what techniques work and that they’re relatively easy to implement,” Dr. Persell said. “Every quality improvement activity takes some resources and prioritization, but we’re very hopeful that these techniques will be adopted by health systems like Northwestern Medicine.”
Although Northwestern clinicians were not involved in this trial, Dr. Persell led a pilot study here in one large practice using the same methods.
This study was supported by the American Recovery & Reinvestment Act of 2009 (RC4 AG039115) from the National Institutes of Health/National Institute on Aging and the Agency for Healthcare Research and Quality.