NEW ORLEANS – The benefits of an 18-month behavioral intervention to reduce inappropriate antibiotic prescribing in the primary care setting were maintained 18 months after the intervention ended, according to follow-up data from a cluster randomized clinical trial.
During the 18-month intervention period, physicians at 47 adult and pediatric practices that participated in the trial, which compared three behavioral interventions and intervention combinations, significantly reduced their inappropriate prescribing.
After 18 months, the results were durable – and particularly so in the groups that received interventions that used “social motivation,” Jeffrey Linder, MD, of Brigham & Women’s Hospital and Harvard Medical School, Boston, reported at an annual scientific meeting on infectious diseases.
A total of 16,959 antibiotic-inappropriate visits (visits for nonspecific upper respiratory tract infections, acute bronchitis, and influenza) were made to 248 clinicians during the 18-month intervention period, and 3,192 such visits were made to 224 clinicians during the postintervention period (JAMA. 2016 Feb 9;315[6]:562-70).
The interventions included “suggested alternatives,” which was an electronic health record-based approach that prompted the prescriber to answer whether a prescription was for an acute respiratory infection. A “yes” answer resulted in the prescriber receiving information about appropriate prescribing, along with a list of “easy nonantibiotic alternatives,” Dr. Linder explained, noting that the interventions involved “trying to make it easy to do the right thing.”
An “accountable justification” intervention used a similar process, but rather than suggesting alternative options, the program asked the prescriber to input a “tweet-length justification” of the prescription. The justification was then entered into the patient’s chart.
The third intervention involved “peer comparison.” Prescribers received monthly e-mail feedback regarding how their prescribing stacked up to that of their peers – specifically noting whether they were or were not “top performers.”
Some of the groups in the trial received combinations of these interventions, but the follow-up analysis showed that the latter two approaches, which involved “social motivation,” had the most durable effects.
For example, the inappropriate antibiotic prescribing rate for those in the “accountable justification” group decreased from 23.2% to 5.2% at the end of the 18-month intervention period (absolute difference, -18.1%) and increased to 9% at the end of follow-up.
The inappropriate prescribing rate decreased from about 20% to about 4% in the “peer comparison” group at the end of the intervention period (absolute difference of -16.3%), then increased to 5% at the end of follow-up, Dr. Linder said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
“The statistically best player here – the peer comparison group – went from 20% to 4% to 5%, so it only went back up 1% even after we turned the intervention off for 18 months,” he said.
Antibiotics often are inappropriately prescribed for acute respiratory infections in primary care. Such infections – including colds, sinusitis, strep throat, nonstrep pharyngitis, acute bronchitis, and influenza – make up only 10% of all ambulatory visits in the United States, but they account for 44% of all antibiotic prescribing, Dr. Linder said.
An estimated 50% of antibiotic prescriptions for acute respiratory infections are inappropriate, he added, noting that little success has been achieved with prior antibiotic stewardship efforts that focused largely on clinician education.
“So, we tried to tackle it a bit differently,” he said. “We saw a persistent significant change in antibiotic prescribing in the peer comparison intervention group. ... I would say that interventions that take advantage of social motivation appear to be effective or persistent.”
Dr. Linder reported having no relevant disclosures.