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JAMA. 2016 Feb 9;315(6):562-70. doi: 10.1001/jama.2016.0275.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial.

Author information

1
Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles2RAND Corporation, Santa Monica, California.
2
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts4Harvard Medical School, Boston, Massachusetts.
3
Anderson School of Management, University of California, Los Angeles6Department of Psychology, David Geffen School of Medicine at UCLA, Los Angeles.
4
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts4Harvard Medical School, Boston, Massachusetts7RAND Corporation, Boston, Massachusetts.
5
Northwestern University, Chicago, Illinois.
6
Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles.

Abstract

IMPORTANCE:

Interventions based on behavioral science might reduce inappropriate antibiotic prescribing.

OBJECTIVE:

To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections.

DESIGN, SETTING, AND PARTICIPANTS:

Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded.

INTERVENTIONS:

Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates).

MAIN OUTCOMES AND MEASURES:

Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians.

RESULTS:

There were 14,753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 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 = .66 for differences in trajectories); from 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 < .001); and from 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 < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions.

CONCLUSIONS AND RELEVANCE:

Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01454947.

PMID:
26864410
DOI:
10.1001/jama.2016.0275
[Indexed for MEDLINE]
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