Published: Jan 27, 2014 | Updated: Jan 28, 2014
By Michael Smith, North American Correspondent, MedPage Today

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A behavioral “nudge” significantly cut inappropriate antibiotic prescriptions for acute respiratory infections in primary care clinics, researchers reported.

In a randomized trial, the nudge — a poster committing a clinician to appropriate use — led to a 9.1 percentage-point drop in inappropriate prescriptions for acute respiratory infections, according to Daniella Meeker, PhD, of the RAND Corp. in Santa Monica, Calif., and colleagues.

In contrast, rates rose slightly among clinicians randomly assigned to follow their standard prescribing practices, Meeker and colleagues reported online in JAMA Internal Medicine.

After controlling for baseline prescribing rates, they reported, the effect of the intervention was a nearly 20 percentage-point reduction in inappropriate use of antibiotics for a decline that was significant (P=0.02).

Displaying poster-sized commitment letters in examination rooms was simple and inexpensive, they concluded, but had an effect “comparable in magnitude to costlier, more intensive quality-improvement efforts.”

Indeed, the researchers “have created a clever judo-like approach that works with patient and clinician psychology to reduce antibiotic prescriptions,” commented Brad Spellberg, MD, of the Liu Vaccine Center in Torrance, Calif.

But how widely the approach can be applied and how long it lasts when it is used both remain up in the air, Spellberg wrote in an accompanying editorial.

And, in any case, the “gentle nudge” did not eliminate the majority of inappropriate antibiotic prescriptions, he argued, suggesting the need for “other novel approaches” — approaches that might include other psychological “judo” or better diagnostics that would help guide appropriate prescribing.

Improper use of antibiotics has lately been in the headlines, with the CDC recently chargingthat for some patients and some conditions, we are already in a “post-antibiotic era.”

Most attempts to cut inappropriate use of antibiotics have assumed that the decisions involved are entirely rational and based on science, Meeker and colleagues reported.

But another model, they noted, suggests that clinicians are also influenced by such things as perceived demand from patients, desire to conform to their peers, and “the need to act in ways that are consistent with one’s previous public commitments.”

The study focused on the latter, randomly assigning doctors in five primary care clinics in the Los Angeles area to sign and display the commitment poster (written at an eighth grade reading level in both English and Spanish) for 12 weeks or to carry on as normal.

All told, 14 clinicians, including 11 doctors and three nurse practitioners, took part in the year-long trial, treating 954 adult patients with visits for acute respiratory infections.

Of those, 449 were treated by clinicians in the intervention group, including 335 in the 40-week baseline period and 114 during the 12-week intervention period. Control clinicians treated the remaining 505, including 384 during the baseline and 121 during the intervention period.

During the baseline period, Meeker and colleagues reported, inappropriate prescribing rates were similar — 43.5% and 42.8% for control and poster groups, respectively.

During the intervention period, however, the rate among the clinicians in the poster group fell to 33.7%, while the rate among the control clinicians rose to 52.7%.

The rate of appropriate prescribing did not fall during the intervention period, they reported. There also was no evidence of diagnostic coding shift.

Meeker and colleagues cautioned that the study had limited geographic range, a handful of clinicians, and a limited length of observation.