Making Better Antibiotic Prescribing Decisions

Antibiotics are an effective means of treating bacterial infections but can cause harm to the individual patient and become less effective for everyone when used incorrectly. The decision to prescribe them for colds and other respiratory infections yields no benefit and imposes costs on the patient and the community.

As many as 2 million Americans suffer from antibiotic-resistant illnesses, with nearly 23,000 dying each year, according to the Centers for Disease Control and Prevention (CDC). Resistance to antibiotics is expected to grow exponentially with continued misuse. By 2050, more people are expected to die from antibiotic resistant illnesses than cancer. Therefore, it is in our best interest to preserve their effectiveness by only using them when they are clearly necessary.

Despite published clinical guidelines for diagnosing and treating nonbacterial infections, recommendations by the CDC, and educational interventions, antibiotic misuse persists. Strategies such as education and reminders assume that physicians are always rational agents, only needing proper information and incentives to make optimal decisions. However, doctors — like everyone else — may sometimes act irrationally. This means more effective solutions will have to take into account that doctors are human beings and subject to the same biases in decision-making as the rest of us.

Following are a few simple, research-driven, and effective tactics to reduce overprescribing of antibiotics:

The first two strategies are based on our most recent study, published in the February 2016 issue of the Journal of the American Medical Association, in which we examined prescription rates of 248 clinicians at 47 primary care practices in Los Angeles and Boston.

One tactic involved appealing to a physician’s professional self-image to be the best doctor that they can be. Using data from electronic health records, physicians were ranked from highest to lowest in terms of inappropriate prescribing rates in their region. The participating doctors then received monthly emails informing them of their performance relative to their peers. Those prescribing according to guidelines were lauded as “top performers,” while those who did not were informed of how they fell short. This approach reduced inappropriate prescribing by an 81 percent, from 19.9 percent in the pre-intervention period to 3.7 percent during the post-intervention period.

The other nudge required physicians to write an “antibiotic justification note” that would be visible in the patient’s file. This brief pause in the workflow, along with the prospect of social accountability, reduced the inappropriate prescribing rate from 23.2 percent to 5.2 percent — a 77 percent reduction.

This work builds upon a 2014 study that was the first to apply the principles of commitment and consistency to prescribing behavior. We had Los Angeles physicians put posters up in their exam rooms explaining safe antibiotic use and also pledge to follow standard guidelines. Each poster provided information in English and Spanish, with a letter featuring the photo and signature of the physician. Over the following three months, we examined clinic records to compare the rates of inappropriate antibiotic prescriptions with a control group that did not display the poster.

The results showed that unnecessary prescriptions differed by nearly 20 percentage points between physicians who used the poster as compared to those who did not. Extrapolated to the entire United States, this low-cost and easily scalable intervention could lead to 2.6 million fewer unnecessary antibiotic prescriptions and $70.4 million in drug savings alone.

Another approach shows that simply regrouping how prescription options are displayed in treatment menus makes a difference. Physicians were roughly 12 percent less likely to order antibiotics unnecessarily if the options were grouped together rather than listed individually.

Finally, when considering that doctors are human, we must take fatigue into account. Physicians make repeated decisions on a daily basis and often work long hours while doing so. This pressure and repetition can weaken their ability to resist inappropriate choices. Psychologists refer to this as decision fatigue, and even the most diligent professional can fall victim to it. Our prescriptions for this malady include better decision support for physicians, modified schedules, fewer continuous work hours, and mandatory breaks.

Whether used together or separately, these simple and inexpensive tactics can be extremely effective in enhancing public health while reducing costs.


Editor’s Note: An Issue Brief summarizing these articles is available here.