Increase Value in Health Care Delivery

    Increase Value in Health Care Delivery

    Using Behavioral Economics to Reduce Inappropriate Antibiotic Prescribing for Acute Respiratory Infections

    Inappropriate antibiotic prescribing for acute respiratory infections is a nationwide problem with severe consequences including inflated health care costs, unnecessary patient side effects, promoting opportunistic infection, and abetting the rise of antibiotic-resistant bacteria. Research led by Jason Doctor at the USC Schaeffer Center has posed and proven multiple solutions to this challenge, including “nudges” based on social psychology and behavioral economics. Doctor and his team were awarded a $11.5 million grant to the USC School of Pharmacy to reduce inappropriate antibiotic prescribing for acute respiratory infections through the use of behavioral economics. Doctor and his colleagues examine the following “nudges “to determine the best method to increase accountability and reduce over prescription:

    • Public Commitments: The researchers had physicians put posters in their exam rooms explaining safe antibiotic use with a photo and signature of the participating physician. The results showed that unnecessary prescriptions were lowered by 20 percentage points in those in received the poster compared to those who did not.
    • Reorganized Electronic Health Record (EHR) Menu Options: Researchers examined the potential of reducing antibiotic over prescribing by regrouping the options posed by EHR layouts. They found that when the aggressive treatment options were grouped together—as compared to when the same options were listed individually—there was a 12 percent decrease in their selection by physicians.
    • Socially Motivated Behavioral interventions- Accountable Justification and Peer Comparison: More recently, Schaeffer Center researchers analyzed the impact of nudges that exploited peer connections and the competitive nature of physicians.
    • Time of Day and Decision Fatigue: Another factor affecting antibiotic over prescription is fatigue resulting from physicians having to make repeated decisions concerning basis as well as clinicians’ frequently long work hours. Researchers found that regardless of whether or not antibiotics were required, the number of prescriptions increased with time. Compared to the first hour, the probability or a prescription for antibiotics increased by 1 percent in the second hour, 14 percent in the third hour and 26 percent in the fourth.

    Their studies, which you can read more about in an issue brief, have significantly reduced inappropriate antibiotic prescribing in the study populations and impacted public health policy across the country and abroad. 

    For example, Doctor and his team have been contacted by policymakers in five states as well as the Centers for Disease Control to help create policies and programs using the insights they have found. The US Surgeon General has requested copies of the strategies and findings. In addition, Public Health England is conducting a study with Prime Minister David Cameron’s Behavioral Insights Team to replicate the earlier results. 

    Doctor has been asked to present his findings to stakeholders across the country.  Most recently, he presented at a meeting of the National Advisory Council on Aging (video) as well as the Behavioral Economics and Policy Association 2016 Conference.

    Collectively, the Schaeffer Center research findings provide policy makers with important new information about how to reduce antibiotic overprescribing to save costs and enhance public health


    Linder, J. A., Doctor, J. N., Friedberg, M. W., Nieva, H. R., Birks, C., Meeker, D., & Fox, C. R. (2014). Time of day and the decision to prescribe antibiotics. JAMA internal medicine, 174(12), 2029-2031.

    Meeker, D., Knight, T. K., Friedberg, M. W., Linder, J. A., Goldstein, N. J., Fox, C. R., ... & Doctor, J. N. (2014). Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA internal medicine, 174(3), 425-431.

    Meeker, D., Linder, J. A., Fox, C. R., Friedberg, M. W., Persell, S. D., Goldstein, N. J., ... & Doctor, J. N. (2016). Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. Jama,315(6), 562-570.

    Persell, S. D., Doctor, J. N., Friedberg, M. W., Meeker, D., Friesema, E., Cooper, A., ... & Linder, J. A. (2016). Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial. BMC Infectious Diseases, 16(1), 373.

    Pineros, D. B., Doctor, J. N., Friedberg, M. W., Meeker, D., & Linder, J. A. (2016). Cognitive reflection and antibiotic prescribing for acute respiratory infections. Family practice, cmw015.


    Jason Doctor
    Jason Doctor
    Director of Health Informatics,
    Schaeffer Center
    Associate Professor,
    School of Pharmacy

    Daniella Meeker
    Daniella Meeker
    Assistant Professor of Preventive Medicine- Pediatrics, Keck School of Medicine of USC