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Physicians need nudging to change old prescribing habits

Researchers say interventions collectively prevented one inappropriate prescription for every eight patients seen.

Jeff Lagasse, Associate Editor

Low-cost approaches that nudge physicians to reduce unnecessary prescriptions for antibiotics could have a significant impact if clinics adopt them for the long term, a USC-led study finds.

Unnecessary antibiotics can harm patients and have contributed to the rise of drug-resistant "superbugs." Initial efforts to curb unnecessary prescriptions of antibiotics have relied on traditional approaches, including education, reminders and alerts -- none of which have been very successful.

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So for a recent study, researchers at USC and other institutions studied three evidence-based psychological approaches known as "nudges" on 248 physicians in Boston and Los Angeles.

Results of the initial study revealed that two interventions significantly reduced inappropriate antibiotic prescribing compared to the control group. One intervention was "peer comparison," in which physicians were updated by a monthly email about their rate of inappropriate prescribing and informed whether they were a "top performer" in comparison to their peers. The other, "accountable justification," required clinicians to report the reason for prescribing antibiotics in the patient's record.

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The two interventions collectively prevented, on average, one inappropriate prescription for every eight patients seen.

Months later, researchers from USC, RAND Corp., Northwestern University and other partner institutions evaluated what would happen when the interventions were removed: Would bad habits return or would physicians continue to thrive as better prescribers?

Their follow-up, published Tuesday in the Journal of the American Medical Association, shows that some clinicians may indeed slip into bad prescription habits without a strategic nudge to motivate them. But the findings also indicate that "nudging" interventions could continue to work if adopted long term.

The interventions are low-cost, and allow the prescribing clinician to retain their decision-making authority while pushing them toward better practices, the research found.

The research is part of a growing field in which researchers consider how human behaviors may factor into economics. The study shows that 12 months after the peer comparison intervention had ended, clinicians increased their antibiotic prescription rate from 4.8 to 6.3 percent. The rate also increased among clinicians who were the subject of the "accountable justification" intervention, from 6.1 to 10.2 percent.

In contrast, the overall rate of inappropriate antibiotic prescribing decreased in control clinics by about 2 percentage points, from 14 to 12 percent.

Given the low cost of the interventions, the authors said it may make sense for clinicians to adopt them permanently.

They also suggested that this enduring effect from peer comparison may be because this intervention did not rely on electronic medical record prompts. Further, the authors said that physicians may have made "judicious prescribing part of their professional self-image" after the study.

However, they also said the persistence of the peer comparison intervention could further diminish as time passes.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com

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