Psychological Nudge Helps Reduce Inappropriate Antibiotic Prescribing

Clinicians whose offices displayed a letter in which they committed to prescribing antibiotics appropriately reduced their rate of inappropriate prescribing, a study finds.

New research suggests that a small push may help reduce rates of inappropriate antibiotic prescribing. The results of the study, published in the January 2014 issue of JAMA Internal Medicine, found that displaying posters in clinicians’ offices affirming their commitment to appropriate antibiotic use led to a significant decrease in inappropriate antibiotic prescriptions for respiratory infections.

Although clinical guidelines advise against using antibiotics to treat acute respiratory infections, and many interventions have been aimed at reducing their use, antibiotics are still overprescribed for these conditions. Previous interventions, however, have ignored psychological factors that affect clinicians’ prescribing decisions and have assumed that clinicians make these decisions in an entirely rational manner. The current study, by contrast, attempted to reduce inappropriate antibiotic prescription by appealing to clinicians’ psychological tendency to act in a manner consistent with a public commitment not to prescribe the medications inappropriately.

Clinicians who treated patients aged 18 and older in 5 outpatient primary care clinics were randomized to an intervention group, which involved displaying a poster-sized commitment letter in their examination rooms, or to a control group. The posters asserted a given clinician’s commitment to avoid inappropriate antibiotic use for respiratory infections and featured a photograph of the clinician and their signature. The commitment letters were posted in February 2012 and were displayed for 12 weeks. Rates of antibiotic prescribing for patients diagnosed with an acute respiratory infection were assessed at baseline and while the posters were on display.

Throughout the study period, 954 adults were diagnosed with respiratory infections by the 14 participating clinicians. At baseline, inappropriate prescribing rates were similar in the intervention and control groups (42.8% and 43.5%, respectively). During the period when the posters were displayed, the rate of inappropriate prescribing dropped to 33.7% in the poster group, but rose to 52.7% in controls. After adjusting for baseline rates, the posters resulted in a 19.7 absolute percentage reduction in inappropriate prescriptions compared with controls. The researchers did not observe an overall decrease in respiratory infection diagnoses or a decrease in the rate of appropriate antibiotic prescribing in the poster group.

“This simple, low-cost, and easily scalable intervention shows great promise in reducing inappropriate antibiotic prescribing and is comparable to prior quality-improvement efforts involving more intensive and costlier designs,” the authors write, noting that the model could avoid millions of inappropriate antibiotic prescriptions and save millions of dollars per year if its results were extrapolated to the entire US population. However, they add that more research is needed to determine how effective the intervention would be in other settings.

In an accompanying editorial, Brad Spellberg, MD, refers to the “nudge” approach as “a clever Judo-like approach that works with patient and clinician psychology to reduce antibiotic prescriptions.” However, Dr. Spellberg notes that although the intervention resulted in a significant drop in prescriptions, the rate of inappropriate prescribing remained high, and additional means of reducing inappropriate antibiotic use will be needed.