A financial incentive policy implemented by the Japanese government in 2018 was associated with a nearly 20% reduction in antibiotic prescriptions in young children, without adverse health outcomes, researchers reported late last week in Clinical Infectious Diseases.
The policy designed by Japan's Ministry of Health, Labor and Welfare (MHLW) aimed to incentivize appropriate antibiotic prescribing in children by allowing eligible outpatient pediatric facilities to claim a small financial reward—800 Japanese yen (US $5.70) per case—when physicians at those facilities do not prescribe antibiotics for children aged 3 and younger who have acute upper respiratory tract infections or gastroenteritis. Physicians were also required to explain to parents or caregivers the rationale for not prescribing antibiotics and provide guidance for home care.
Part of Japan's National Action Plan on Antimicrobial Resistance, the policy was prompted in part by a 2015 global survey that ranked Japan lowest among 36 high-income countries in appropriate antibiotic prescribing for children. In April 2020, the MHLW expanded the age eligibility for the policy from 3 to 6 years.
Sustained reductions in prescribing
To evaluate the long-term impacts of the policy, a team led by researchers from Japan's National Center for Child Health and Development conducted a quasi-experimental study in which they analyzed data from two nationwide administrative databases on 165,113 propensity-score matched children born from April 2017 through March 2019. They tracked the children until May 2022, comparing antibiotic prescriptions and healthcare use in those exposed to the policy with those who were not.
The analysis found that the introduction of financial incentives was associated with a 44.9% relative reduction in total antibiotic prescriptions within the first month and a 19.5% reduction over 48 months. Broad-spectrum antibiotic use fell by 24.4% over the same period.
Although the policy was associated with a slight increase in the number of office visits, there was no excess increase in after-hours visits, and hospitalizations fell over the study period. In addition, the incentive policy was not associated with changes in healthcare and drug costs.
A dose-response relationship was observed, with reductions in antibiotic use leveling off after approximately five incentives.
"Our study provides evidence that financial incentive-induced behavioral changes in physicians are an effective tool for reducing antibiotic use, demonstrating sustained benefits without adverse healthcare consequences," the study authors wrote.
Strategy empowers physicians
The authors say the reward system worked because it was a more constructive approach than penalization and enabled the Japanese government to clearly communicate its commitment to reducing antibiotic use in children without blaming physicians.
"Consequently, this decision changed physicians' behavior, which influenced the perceptions of children and caregivers, leading to cascading reactions that produced long-lasting public health benefits," they wrote.
The sustained effect of the policy, they add, was mainly attributable to allowing repeated rewards to medical facilities, even for the same patients. As a result, physicians at these facilities became accustomed to explaining to caregivers the reasons for not prescribing antibiotics. Caregivers benefited as well.
"Additionally, this repeated education likely enhanced learning for caregivers," they wrote. "Although caregivers might initially have anxiety about not receiving antibiotics, consistent and repetitive explanations across different instances reinforced their knowledge, helped them accept the natural course of viral infections, and reduced their anxiety."
In an accompanying editorial, antimicrobial stewardship experts with the Washington University in St. Louis School of Medicine and the VA Pittsburgh Healthcare System say the incentive policy is a good example of the "behavioral boost" strategy that's recently been introduced in antimicrobial stewardship programs. Unlike behavioral "nudges" like peer comparison, they explain, behavioral boosts emphasize individual empowerment.
"Simply stated, the intervention supported the prescribers' agency in making clinical decisions," they wrote. "The policy change affirmed the importance of physician-patient relationships. Empowering physicians to provide good healthcare that also helps their healthcare organization was a remarkably effective behavioral boost."
