In cases of accountable justification and peer comparison, study participants were less likely to prescribe antibiotics against guideline recommendations. From MedPage Today.
This article originally appeared in MedPage Today.
Having to justify an antibiotics prescription for acute respiratory tract infections, or being compared with their peers for number of scripts written, lowered rates of inappropriate antibiotic prescribing practices for up to 18 months among primary care physicians, researchers reported.
After receiving an educational intervention, primary care clinicians were randomized to intervention groups: In the electronic health records (EHR) system, they either received a suggestion prompt for a non-antibiotic (suggested alternatives), a justification prompt (accountable justification), or received emails showing how they ranked against their colleagues (peer comparison).
In the cases of accountable justification and peer comparison, study participants were less likely to prescribe antibiotics against guideline recommendations, wrote Jason N. Doctor, PhD, of the University of Southern California in Los Angeles, and colleagues in the Journal of the American Medical Association.
The mean antibiotic prescribing rates decreased as follows:
- 24.1% at the start of the intervention to 13.1% at month 18 (absolute difference −11.0%) for control practices
- 22.1% to 6.1% (absolute difference −16.0%) for suggested alternatives (difference in differences −5.0%, 95% CI −7.8% to 0.1%. P=0.66 for differences in trajectories)
- 23.2% to 5.2% (absolute difference −18.1%) for accountable justification (difference in differences −7.0, 95% CI −9.1% to −2.9%, P<0.001)
- 19.9% to 3.7% (absolute difference −16.3%) for peer comparison (difference in differences −5.2%, 95%CI −6.9% to −1.6%, P<0.001)
In an accompanying editorial, Jeffrey S. Gerber, MD, PhD, of The Children's Hospital of Philadelphia, noted that "even though the relative reductions in inappropriate prescribing rates were modest, they are real, important, and potentially sustainable."
"Even when an antibiotic is indicated, often the wrong one is chosen: roughly half of antibiotics for children are broad- spectrum, second-line agents, and the most commonly prescribed antibiotic for adults is azithromycin, despite this drug being recommended as the first-line choice for relatively few conditions" he stated.
"Factors other than specific medical need drive prescribing behavior. These include perceived patient (or parent) pressure, the presence of trainees, and even the time of day or the race of the patient," Gerber explained.
Gerber called the results from these "simple interventions" promising. "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," he said.
Doctor's group randomized 47 primary care practices in Boston and Los Angeles, where, over the course of 18 months, 248 clinicians received one of three interventions, or none at all.
Upon enrollment, each of the clinicians was educated on guideline-concordant antibiotic prescribing for acute respiratory tract infections, nonspecific upper-respiratory infections, acute bronchitis, and influenza. The practices were compensated for physician participation.
Reference prescribing rates were taken from 14,753 patient visits during the 18 months prior to intervention, and compared with the antibiotic prescribing rates for 16,959 visits during the 18 months after interventions were implemented. Patients who had comorbid conditions or other infections were excluded.
The three interventions were:
- In the EHR, an electronic order was set to suggest non-antibiotic treatments
- In the EHR, an electronic order prompted clinicians to enter free-text explaining why they prescribed the antibiotics
- Emails were sent to clinicians comparing his or her antibiotic prescribing rates with those of "top performers," a designation given to clinicians with the lowest inappropriate prescribing rates
Doctor and colleagues noted that peer comparison was different from traditional "audit-and-feedback interventions" because clinicians had their prescribing habits ranked against top-performing peers instead of average-performing peers.
This delivery of positive reinforcement to top performers is a strategy shown elsewhere to sustain performance, they added.
While the two "socially motivated interventions" led to statistically significant reductions in inappropriate antibiotic prescribing, the one that lacks a social component (suggested alternatives) had no statistically significant effect, the authors noted.
"There were no statistically significant interactions between interventions; therefore, applying these interventions simultaneously might have additive effects on antibiotic prescribing," they pointed out.
However, return visits for possible bacterial infections within 30 days following visits for acute respiratory tract infection where antibiotic were not prescribed were significantly higher in the accountable justification plus peer comparison group (1.41%, 95% CI 1.06%-1.85%) versus control practices (0.43%, 95% CI 0.25%-0.70%). This held true in "both antibiotic-inappropriate and potentially antibiotic-appropriate" cases, the authors stated.
"No other intervention group (including the group applying all 3 interventions simultaneously) had a statistically significantly higher rate of such return visits," they wrote.
Study limitations included small cluster sizes and the fact that results were dependent on EHR and billing data. Gerber pointed out that clinicians were compensated $1,200 each for participation, "which might have influenced the buy-in of study participants and also potentially limits generalizability."