Displayed commitment from doc could reduce unnecessary antibiotic prescribing by 20%

"Nudging" doctors with signed commitment letter in exam rooms lowered inappropriate antibiotic prescriptions for cold symptoms by nearly 20%, according to a study in JAMA Internal Medicine.

To test the impact of public commitment on health behavior, researchers at the University of Southern California Schaeffer Center for Health Policy and Economics had physicians post a large letter about inappropriate antibiotic prescription in their exam rooms. The letter, displayed in both English and Spanish in Los Angeles clinics, had a picture of the physician and his/her signature, and explained the physician’s commitment to reducing inappropriate prescriptions for acute respiratory infections, such as the common cold.

The researchers then looked at clinic records over the next 3 months, comparing rates of inappropriate antibiotic prescriptions to a control group that did not sign or post a public commitment poster.

A signed commitment poster dramatically decreased unnecessary antibiotic prescriptions: among physicians who posted the letter, inappropriate antibiotic prescriptions fell nearly 10 percentage points, to 33.7% of total antibiotic prescriptions from 42.8% in the year before the study. This also could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million in drug costs alone if extrapolated across the United States.

In contrast, inappropriate antibiotic prescriptions actually increased in the control group, who started with a similar 43.5% inappropriate prescription rate. Over the study period, the prescription of antibiotics in instances where they would not be effective rose to 52.7% among those who did not post a commitment poster.

Importantly, rates of appropriate antibiotic prescription did not change, the researchers found. There also was no evidence of changes to how illnesses or diagnoses were coded by clinicians.

Inappropriate antibiotic prescriptions are a major public health concern, costing millions of dollars in unnecessary healthcare costs annually and contributing to the problem of antibiotic-resistant bacteria. In the United States, nearly half the antibiotic prescriptions given for respiratory infections are inappropriate: for illnesses caused by viruses rather than bacteria, antibiotics won’t help the patient get better.

“Most quality improvement efforts have used audits or pay-for-performance incentives to try to change what providers do, but they ignore social influences that affect all people, including physicians,” said senior author Jason Doctor of the USC Schaeffer Center for Health Policy and Economics, and associate professor of clinical pharmacy and pharmaceutical economics and policy at the USC School of Pharmacy. “Our study is the first to apply the principles of commitment and consistency to prescribing behavior and finds a simple, low-cost intervention that shows great promise in reducing inappropriate antibiotic prescription.”

Lead author Daniella Meeker of RAND Corporation and Merkin Fellow at the USC Schaeffer Center for Health Policy and Economics said that the findings from the study support the idea that clinicians are influenced by professional and social factors in patient care, “and unlike some quality improvement interventions based upon financial incentives, we found no evidence that improvements were driven by changing documentation practices,” she said. “This low-cost and easily scalable intervention has great potential to reduce inappropriate antibiotic prescribing,” Meeker said.

The study did not look at why physicians might be inclined to overprescribe antibiotics, but possible explanations from other research include patient demand and “defensive” prescribing.