Behavioral approach may boost appropriate prescribing

A new Dutch study suggests that an approach to antimicrobial stewardship that lets prescribers determine the best intervention can improve appropriate prescribing.

The results from the multicenter study, published this week in JAMA Internal Medicine, showed that implementing an antimicrobial stewardship program (ASP) that's grounded in behavioral theory and focuses on preserving prescriber autonomy improved appropriate prescribing by 21% in participating hospitals over the course of a year. The authors of the study say the approach is suitable for a variety of hospital settings.

"Our approach offers good potential for implementation in other hospitals, even in resource-challenged circumstances, because it adapts to local possibilities, requires no expensive investments, and is successful in surgical, medical, and pediatric settings," the authors write.

Approach emphasizes prescriber autonomy

The study, performed from October 2011 through December 2015, involved seven departments in two Dutch hospitals—a 700-bed tertiary care center and a 550-bed teaching general medical center—and included surgical, medical, and pediatric departments. The departments were selected based on the results of a 12-month baseline survey of antimicrobial appropriateness and consumption, but participation in the study was voluntary.

The aim of the study was to test the effectiveness of a stewardship approach in which prescribers were asked to determine the root causes of inappropriate antimicrobial prescribing in their department, then develop one or more interventions to improve prescribing based on those root causes. The theory behind this strategy is that if you respect prescriber autonomy and allow prescribers to create their own program to improve prescribing, they will value this approach more and show more commitment to it.  

This behavioral strategy, the authors explain, is an acknowledgment that prescriber resistance can sometimes be an impediment to stewardship and that ASPs tend to focus more on changing systems than on changing human behavior. 

"Despite its rational theoretical foundation, stewardship programs are known to persistently encounter prescriber resistance," they write. "This resistance is generated by the tension between the governance of the stewardship team and the autonomy of individual prescribers."

After the 12-month baseline survey of antimicrobial prescribing and consumption, prescribers in each department were asked to do a root-cause analysis in which they identified causes of inappropriate prescribing that fell into four broad categories: physician (eg, inexperience or lack of knowledge among physicians), culture (eg, prudent antimicrobial use not considered important), organization (eg, heavy workload and poor supervision), and guidelines (eg, conflicting or hard to find or use).

Each department then chose interventions linked to those themes. For example, a department that identified resident inexperience, lack of supervision, and unclear guidelines as root causes called for guideline revision, more commitment to appropriate prescribing from supervisors, and increased focus on antibiotics during ward rounds. The departments also chose one or more antibiotic ambassadors.

The primary outcome of the study was antimicrobial appropriateness, which included indication, choice of drug, dosage, administration route, and duration. Appropriateness was measured through point prevalence surveys six times per year. Antimicrobial consumption, reported in days of therapy per 100 admissions per month, was the secondary outcome.

Increase in appropriate prescribing

Overall, there were 21,306 clinical admissions during the baseline period and 15,394 clinical admissions during the intervention period, with the appropriateness surveys including 1,121 patients and 882 patients, respectively. In the baseline period, 64.1% of antimicrobial prescriptions were considered appropriate, compared with 77.4% in the intervention period, an increase of 20.7% that equaled 4,927 improved days of therapy.

Broken down by category, the intervention period saw reductions in unnecessary antimicrobial use, inappropriate choice of antibiotics, and inappropriate dosage. Antimicrobial consumption, however, did not decrease significantly during the intervention period.

The authors say the findings are clinically relevant because the manner in which they defined appropriateness "specifically focused on unwanted prescriptions from a stewardship point of view."

"Attainment of underlying goals, such as empirical therapy, according to guidelines and de-escalation of therapy improves mortality and other clinical outcomes," they write.

They argue that finding no reduction in antimicrobial consumption during the intervention period doesn't necessarily suggest a failure of the stewardship interventions, since overall antimicrobial use doesn't necessarily shed light on the appropriateness of therapy.  

The effectiveness of the behavioral approach, the authors explain, is that it emphasizes prescriber independence in crafting a solution to inappropriate antimicrobial use.

"We hypothesize that participating department members felt relatively nonthreatened by our approach because of their freedom in choosing a personal solution, which is an important theme in antimicrobial stewardship," they write. "Moreover, by committing to the project and choosing and developing their own intervention set, they may have felt more inclined to support the project and change their own prescribing behavior."

Limitations of the study include the fact that the prescribers were aware of being monitored, which could have led to changes in behavior. In addition, because the Dutch healthcare system differs from others, the findings may not be generalizable.

See also:

May 1 JAMA Intern Med study

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