Without a ‘Nudge;’ Old Prescribing Habits Die Hard

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.

At least one in three antibiotic prescriptions for acute respiratory infections in the US is unnecessary. These unnecessary antibiotics can harm patients and increase antibiotic resistance. Initial efforts to curb unnecessary prescribing of antibiotics relied on education, reminders and alerts—none of which were very successful.

Recent studies by a team of researchers from USC, Northwestern, RAND, UCLA and other institutions have turned to the fields of psychology and behavioral economics– using interventions to curtail antibiotic overprescribing that appeal to a physician’s professional self-image.

Now these researchers have completed a new study that appears in the Journal of the American Medical Association looking at the nature of this behavior change. Specifically, they evaluated what happens when these interventions are removed: do bad habits return or do physicians continue to thrive as better prescribers?

“Our previous studies showed that two relatively low-cost interventions significantly reduced inappropriate physician prescribing,” said Jason Doctor, director of informatics of the USC Schaeffer Center for Health Policy & Economics, corresponding author on the study. “In this study, we wanted to see if the positive change persisted twelve months after the interventions were stopped.”

The answer is that at least one of the interventions does have some staying power once the interventions were no longer in place but…

“Given the impact during the study period and the relatively low cost of the interventions, it may make sense for clinics to permanently retain the interventions,” said Jeffrey Linder, lead author, who is a professor of medicine at the Northwestern University Feinberg School of Medicine.

Their research is part of a growing field in which researchers consider how human behaviors may factor into economics. The research area received its due this week when the Nobel Memorial Prize of Economic Sciences was awarded to economist Richard D. Thaler, a University of Chicago professor and author of the economics book “Nudge.”

Study Results – During the Intervention and After the Intervention

The initial study, published in JAMA in 2016, followed 248 primary care clinicians in Boston and Los Angeles, evaluating whether the three “nudging” interventions, based on behavioral economics insights, impacted physician prescribing. The interventions included:

  • Peer Comparison where, based on their rate of inappropriate antibiotic prescriptions, clinicians were told in a monthly email either “you are a top performer” or “you are not a top performer.”
  • Accountable Justification where a prompt requested the clinician to justify a prescription as it is being entered in a patient’s electronic record. The written justification was added to the chart, unless the clinician cancelled the prescription.
  • Suggested Alternative where a pop-up box encouraged alternative, non-antibiotic treatments whenever a clinician ordered an antibiotic for acute respiratory infection in a patient chart.

During the active phase, each physician received none or some combination of the nudging interventions. The researchers found peer comparison and accountable justification each significantly reduced inappropriate antibiotic prescribing in comparison to the control group, by 16 percentage points and 18 percentage points, respectively. The third nudge, suggested alternative, had no statistically significant effect.

In this latest study, during the post intervention period, the researchers found clinicians who had received the peer comparison intervention increased their rates of antibiotic prescribing from approximately 5 to 6 percent and accountable justification increased from 6 to 10 percent. In comparison, the rate of inappropriate antibiotic prescribing decreased in control clinics by about 2 percentage points (from 14 to 12 percent).

Making a Lasting Impact

Notably, peer comparison had the greatest staying power 12 months after the intervention had stopped. The authors suggest this may be because this intervention did not rely on electronic medical record prompts. Further, the authors say that physicians may have made “judicious prescribing part of their professional self-image” after the study. The authors note that the persistence of this intervention may further diminish as time passes.

“These interventions are low-cost and allow the prescribing clinician to retain their decision making authority while nudging them toward better practices,” said Doctor.

Inappropriate antibiotic prescribing results in 47 million excess prescriptions each year that put patients at health risks and contribute to the growing problem of antibiotic resistance. Several national campaigns undertaken to reduce inappropriate antibiotic prescribing using various incentives and other policies have been only moderately effective.

The study authors conclude that behavioral interventions designed to influence clinical decision making are most effective when applied long term.

Other authors on the study include Danielle Meeker, University of Southern California; Craig R. Fox, University of California-Lost Angeles; Mark W. Friederg, RAND Corporation; Stephen D. Persell, Northwestern University; and Noah J. Goldstein, University of California-Los Angeles.

This study was supported by the National Institutes of Health, National Institute on Aging, and the Agency for Healthcare Research and Quality.