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Randomized Controlled Trial
. 2016 Aug 5:16:373.
doi: 10.1186/s12879-016-1715-8.

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

Stephen D Persell  1   2 , Jason N Doctor  3 , Mark W Friedberg  4   5 , Daniella Meeker  3   6 , Elisha Friesema  7   8 , Andrew Cooper  7 , Ajay Haryani  7 , Dyanna L Gregory  7 , Craig R Fox  9 , Noah J Goldstein  9 , Jeffrey A Linder  4
Affiliations
Randomized Controlled Trial

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

Stephen D Persell et al. BMC Infect Dis. .

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.

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Figures

Fig. 1
Fig. 1
Percentage of eligible visits with antibiotic prescribed for visits with non-antibiotic appropriate diagnoses and all ari diagnosis categories combined by quarter. (Black Square) All eligible visits for acute respiratory infections. (Gray Diamond) Eligible visits for non-antibiotic-appropriate acute respiratory infections. Error bars represent 95 % confidence intervals. ARI: acute respiratory infection
See this image and copyright information in PMC

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