In the year after behavioral interventions designed to improve antibiotic stewardship ended, clinicians' rates of inappropriate prescribing increased, although one of three intervention groups was still outperforming a control group after a year, according to a report today in the Journal of the American Medical Association (JAMA).
Physicians who saw their prescribing rates compared with those of top stewardship performers over the 18-month intervention were still doing significantly better than controls a year after the intervention ended. Physicians who received two other types of stewardship interventions—"suggested alternatives" and "accountable justification"—were not performing significantly better than controls after a year.
The new report, presented in a letter, describes an extension of a study reported in JAMA in February 2016. That study involved 248 clinicians at 47 practices in Boston and Los Angeles who were randomly assigned to receive one or more of the three interventions, or no intervention. The aim was to reduce inappropriate prescriptions for adults presenting with acute upper respiratory tract infections (ARIs), acute bronchitis, or influenza.
The suggested-alternatives intervention involved using electronic health records (EHR) to suggest nonantibiotic treatments for ARIs, while accountable justification relied on prompting physicians to write justifications for prescribing antibiotics.
In peer comparison, physicians received monthly emails that compared their inappropriate prescribing rates with clinicians who had the lowest rates. All the groups received education about antibiotic prescribing guidelines.
In the original study, inappropriate-prescription rates fell for all the groups, including the control group, but the accountable justification and peer comparison groups had significantly greater decreases than the control group, whereas the suggested alternatives group did not.
In the follow-up study, the clinicians' prescribing practices were monitored for 12 months after the interventions ended. They had a total of 7,489 patient visits for antibiotic-inappropriate ARIs during that year. To assess the persistence of the effects of each intervention, the authors used a model that adjusted for exposure to other interventions and for practice-level and clinician-level effects.
The rate of inappropriate prescribing in control clinics dropped from 14.2% to 11.8% over the post-intervention year, continuing a long-term trend, according to the report. In contrast, the rates increased in all of the intervention groups: from 7.4% to 8.8% for suggested alternatives, from 6.1% to 10.2% for accountable justification, and from 4.8% to 6.3% for peer comparison. But the peer comparison group's rate remained significantly lower than that of controls, whereas the rate for the suggested alternatives and accountable justification groups did not.
Peer comparison and self-image
"There was still a statistically significant difference between peer comparison and control practices 12 months after the interventions were removed, possibly because this intervention did not rely on EHR prompts whose absence might have been quickly noted by clinicians," the researchers wrote. "Peer comparison might also have led clinicians to make judicious prescribing part of their professional self-image."
The authors noted that their findings differ from a previous antibiotic intervention study using audit and feedback, in which inappropriate prescribing returned to baseline levels after the intervention ended. In contrast, they said, "Peer comparison-induced improvements have been durable in other nonmedical domains."
The study's limitations were that it included only volunteers from selected clinics and that the follow-up was just 1 year, the authors said.
"These findings suggest that institutions exploring behavioral interventions to influence clinician decision making should consider applying them long term," they concluded.
Being watched fosters compliance
Debra Goff, PharmD, an antimicrobial stewardship expert who was not involved in the study, praised the findings. She is an infectious disease specialist and founding member of the Antimicrobial Stewardship Program (ASP) at The Ohio State University Wexner Medical Center in Columbus.
"This is a great study and helps ASP learn what behavior change interventions are sustainable, which is very important because ASP can't study and monitor every intervention forever," she commented by email.
"Human nature is to do better and comply when you know you're being watched," she added. "So in my opinion the value of this study is that it shows that only peer comparisons were sustainable. Most likely it's because physicians are competitive AND public shaming works. No one wants to be a 'low performer.'"
Oct 10 JAMA letter introduction
Oct 10 JAMA news release
Original intervention study reported in JAMA in 2016
Feb 10, 2016, CIDRAP News scan on earlier report