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JAMA Intern Med. 2014 Mar;174(3):425-31. doi: 10.1001/jamainternmed.2013.14191.

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.

Author information

1
RAND Corporation, Santa Monica, California.
2
Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles.
3
RAND Corporation, Boston, Massachusetts4Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts.
4
Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts.
5
Anderson School of Management, University of California, Los Angeles.
6
COPE Health Solutions, Los Angeles, California.
7
QueensCare Family Clinics, Los Angeles, California.

Abstract

IMPORTANCE:

"Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice.

OBJECTIVE:

To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs).

DESIGN, SETTING, AND PARTICIPANTS:

Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention).

INTERVENTIONS:

The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs.

MAIN OUTCOMES AND MEASURES:

Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status.

RESULTS:

Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (Pā€‰=ā€‰.02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time.

CONCLUSIONS AND RELEVANCE:

Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.

TRIAL REGISTRATION:

clinicaltrials.gov identifier: NCT01767064.

PMID:
24474434
PMCID:
PMC4648560
DOI:
10.1001/jamainternmed.2013.14191
[Indexed for MEDLINE]
Free PMC Article

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