Skip to main content

Pledges Reduce Inappropriate Antibiotic Prescribing Rates

 |  By cclark@healthleadersmedia.com  
   January 28, 2014

In a study, antibiotic prescription rates for antibiotic-inappropriate diagnoses dropped after clinicians posted photos of themselves alongside signed pledges to "avoid prescribing antibiotics when they are likely to do more harm than good."

Clinicians are less likely to inappropriately prescribe antibiotics if they sign and display "commitment" pledges—with photos of themselves—on their exam room walls, says a paper by researchers in Boston and Los Angeles.

"We found this is a new way to improve healthcare through medicine," says one of the authors, Jason N. Doctor, a health economist at the University of Southern California School of Pharmacy.

"In the past, we've focused on [preventing inappropriate prescribing by] stopping [doctors'] work flow by giving them alerts and reminders, trying to appeal to reason and educating them.

"What we did here is we treated these doctors more like social animals who are affected more by social interactions with others," Doctor says. "We leveraged the fact that these physicians want to appear consistent, and when we hold them accountable through this commitment device, we found that they do change their behavior."

The paper was published in Monday's issue of JAMA Internal Medicine. The research project was funded by the National Institute on Aging. Researchers from Brigham and Women's Hospital in Boston, Harvard Medical School, and the University of California Los Angeles, and clinicians from Queens Care Family Clinics in Los Angeles participated.

The 12-week experiment, conducted during flu season in 2011, took place in five outpatient primary care federally qualified health centers.

During a baseline period, 14 clinicians divided into two groups prescribed antibiotics inappropriately to patients with viral infections about 43% of the time in each group. Both groups received a reminder about basic guidelines in antibiotics at the start of trial.

Then the two groups were divided. Clinicians in the intervention group signed letters of commitment that were blown up on 18" by 24" posters that also carried their photographs. The posters were hung at the patient's eye level in the exam rooms and said, in part:

Antibiotics, like penicillin, fight infections due to bacteria that can cause some serious illnesses. But these medicines can cause side effects like skin rashes, diarrhea, or yeast infections. If your symptoms are from a virus and not from bacteria, you won't get better with an antibiotic…"

The posters explain that antibiotics make bacteria more resistant, which makes future infections harder to treat, and less likely to work "when you really need them."

In the group of doctors whose office walls displayed the posters, inappropriate prescribing decreased to 33.7%. For the group of doctors whose office walls did not carry the personalized posters, inappropriate prescribing increased to 52.7%.

Co-author Daniella Meeker, associate information scientist at the RAND Corp., says that other studies that tested the effectiveness of posters haven't been as effective because they were more generic, and lacked the physician's personal signature and photo.

Inappropriate prescribing was determined through electronic health records which classified patients' illnesses according to ICD-9 diagnostic code. For nine of these codes, evidence agrees that physicians should never prescribe antibiotics. For another 16 ICD-9 codes, antibiotic prescriptions were said to be "appropriate."

According to the Centers for Disease Control and Prevention, antibiotic-resistant bacteria "pose a catastrophic threat." At least two million people in the United States becoming infected each year with a resistant bacteria that kills at least 23,000 and is a major of c. difficile infections, which can be provoked by antibiotics and which results in 250,000 hospitalizations annually.

In an accompanying invited commentary, Brad Spellberg, MD, of the Lieu Vaccine Center in Torrance, CA, wrote that "new ideas, such as the simple and gentle public commitment concept Meeker and colleagues have developed, are needed to work in concert with traditional approaches to help us change the future state of antibiotic resistance."

The researchers say they are working on several follow-up studies, one of which attempts to understand reasons why physicians prescribe antibiotics for patients who do not have a bacterial infections, such as, pressure from patients.

Tagged Under:


Get the latest on healthcare leadership in your inbox.