Can behavioral science help improve antibiotic prescribing?

Could a little "nudging" discourage inappropriate antibiotic prescribing?

In a March 2014 study on outpatient prescribing in JAMA Internal Medicine, a team of researchers looked at the impact of an intervention at five primary care outpatient clinics that was based on the concept of the behavioral "nudge."

In the randomized trial, one group of patients being treated for acute respiratory infections were treated by doctors who had poster-size letters stating their commitment to appropriate prescribing displayed in their exam rooms. The study found that the rate of inappropriate prescribing was nearly 20% lower among the physicians displaying these commitment posters, compared to those who didn't participate in the poster intervention.

This intervention is just one example of behavioral science techniques that could be woven into efforts to reduce inappropriate outpatient prescribing, according to a new report from the Pew Charitable Trusts. These techniques acknowledge that clinician decisions, especially when it comes to prescribing antibiotics for conditions like acute respiratory infection, aren't always based on medical knowledge or training. Instead, they are often influenced by psychosocial factors like perceived patient demand, which can lead to overprescribing.

"If the provider perceives that [antibiotics] are what the patient wants, then that can be a key driver in their decision to prescribe antibiotics," report author David Hyun, MD, a senior officer with the Pew Charitable Trusts antibiotic resistance project, told CIDRAP News. "Even in situations where the patients may not actually have an expectation of antibiotics.

"There are a lot of limitations, and not enough tools to adequately address that perceived pressure," he said.

Behavioral approaches

The nudging strategy is an effort to use psychosocial factors to push the needle back toward more responsible antibiotic prescribing. It's an alternative to more traditional stewardship strategies that have been shown to have a positive impact on prescribing in outpatient settings, such as educational initiatives, prospective audit and feedback, and clinical decision support systems.

For Hyun, those strategies—which assume that clinical decisions are based on scientific knowledge about best practices—are a good starting point, but may not be enough to counteract the social factors that influence prescribing.

"It's not just about beefing up the medical knowledge about when antibiotics are appropriate," Hyun said. "It's also about trying to stimulate these social motivations to amplify the effects of the types of stewardship activities that are currently in place."

The idea behind the commitment poster study, which is cited in the Pew report, is to reduce inappropriate prescribing by appealing to a physician's desire to adhere to commitments they make publicly. It's based on social psychology research that suggests people who make public commitments to specific behaviors are more likely to follow through with the expressed intentions. "Putting that kind of public accountability and visibility to it provided extra motivation to do better," Hyun said.

Harnessing the power of 'peer comparison'

In another example of nudging cited in the Pew report, researchers looked at the effect of an intervention in which physicians who were ranked as having the lowest inappropriate prescribing rates were told monthly via email that they were "top performers," while the remaining physicians were told they were not top performers. When this intervention was compared to the use of clinical decision support in a control group, researchers found it resulted in lower rates of inappropriate prescribing.

"By framing it that way, it adds an extra element," Hyun said of the "peer comparison" approach, which takes the audit and feedback strategy a step further by comparing physicians not to average-performing peers but to top-performing peers. "Providers look at that, and have an extra motivation that they want to do as well as, or even better, than their peers." 

The Pew report acknowledges that other, non-social factors, such as diagnostic uncertainty and time constraints, also affect outpatient prescribing, and that the nudging approach doesn't address these issues. But Hyun believes that understanding all the elements that influence antibiotic prescribing can help create better stewardship strategies for outpatient clinics, strategies that will help address the underlying social factors and improve the communications between patient and provider.

So in addition to a little nudging, clinicians also need more time and better communication skills, Hyun added, to be able to talk with their patients about why antibiotics aren't always necessary.

See also:

Jun 28 Pew Charitable Trusts issue brief

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