Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial.
BACKGROUND
Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.


METHODS
Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.


RESULTS
We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995).


CONCLUSIONS
We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.


TRIAL REGISTRATION
ClinicalTrials.gov: NCT01454960 .
['Persell|Stephen D|SD|', 'Doctor|Jason N|JN|', 'Friedberg|Mark W|MW|', 'Meeker|Daniella|D|', 'Friesema|Elisha|E|', 'Cooper|Andrew|A|', 'Haryani|Ajay|A|', 'Gregory|Dyanna L|DL|', 'Fox|Craig R|CR|', 'Goldstein|Noah J|NJ|', 'Linder|Jeffrey A|JA|']
D000208:Acute Disease D000328:Adult D000900:Anti-Bacterial Agents D001519:Behavior D003657:Decision Making D020000:Decision Support Systems, Clinical D004502:Education, Medical, Continuing D005260:Female D006801:Humans D057970:Inappropriate Prescribing D007400:Interprofessional Relations D008297:Male D008875:Middle Aged D010612:Pharyngitis D058007:Physicians, Primary Care D010865:Pilot Projects D010818:Practice Patterns, Physicians' D055656:Prescriptions D012141:Respiratory Tract Infections D012852:Sinusitis
Antibiotics Acute respiratory infections Behavioral economics Clinical decision support Social psychology