Harnessing the wisdom of crowds can improve guideline compliance of antibiotic prescribers and support antimicrobial stewardship

open access articleAntibiotic overprescribing is a global challenge contributing to rising levels of antibiotic resistance and mortality. We test a novel approach to antibiotic stewardship. Capitalising on the concept of “wisdom of crowds”, which states that a group’s collective judgement often outperforms the average individual, we test whether pooling treatment durations recommended by different prescribers can improve antibiotic prescribing. Using international survey data from 787 expert antibiotic prescribers, we run computer simulations to test the performance of the wisdom of crowds by comparing three data aggregation rules across different clinical cases and group sizes. We also identify patterns of prescribing bias in recommendations about antibiotic treatment durations to quantify current levels of overprescribing. Our results suggest that pooling the treatment recommendations (using the median) could improve guideline compliance in groups of three or more prescribers. Implications for antibiotic stewardship and the general improvement of medical decision making are discussed. Clinical applicability is likely to be greatest in the context of hospital ward rounds and larger, multidisciplinary team meetings, where complex patient cases are discussed and existing guidelines provide limited guidance

Reasons for Cooperating in Repeated Interactions: Social Value Orientations, Fuzzy Traces, Reciprocity, and Activity Bias

Many human interactions involve patterns of turn-taking cooperation that can be modeled by the deeply paradoxical Centipede game. A backward induction argument suggests that cooperation is irrational in such interactions, but experiments have demonstrated that players cooperate frequently and earn better payoffs as a consequence. We formulate 6 competing theories of cooperation in Centipede games and report the results of 2 experiments, based on investigations of several closely matched games with different payoff structures and different methods of reaching decisions. The results show that turn-taking cooperation does not appear to be explained by reciprocity theory, activity bias theory, or a motive to maximize relative payoffs, but that collective rationality, in the form of a motive to maximize joint payoffs, and fuzzy-trace theory can explain cooperation in interactions of this type. Reciprocity increases cooperation across repeated games between fixed player pairs, but there is no evidence of reciprocity influencing cooperation within games

Optimizing antibiotic prescribing : collective approaches to managing a common-pool resource

CITATION: Tarrant, C., et al. 2019. Optimizing antibiotic prescribing : collective approaches to managing a common-pool resource. Clinical Microbiology and Infection, 25(11):1356-1363, doi:10.1016/j.cmi.2019.03.008.The original publication is available at https://www.clinicalmicrobiologyandinfection.com/Background: Antimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterized as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximize individual payoffs, although the collective outcome is worse if all act in this way. Objectives: We aim to outline the implications for antimicrobial stewardship of characterizing antibiotic overuse as a social dilemma. Sources: We conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas. Content: The social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms. Implications: We conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimizing antibiotic prescribing more tractable, providing a theory base for intervention development.https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(19)30110-7/fulltext#relatedArticlesPublisher's versio

Sepsis and Antimicrobial Stewardship – Two Sides of the Same Coin

Sepsis and antimicrobial stewardship (AMS) programmes co-exist in healthcare settings; however, there can be tension between the goals of reducing sepsis mortality, and preventing antimicrobial resistance (AMR). How these goals are perceived and prioritised by health professionals and the public is likely shaped by media framing and compounded by nonalignment of sepsis and AMS programmes in healthcare organisations. Media sepsis reports use personal stories with solutions within the power of individuals whereas AMR is framed as a vague future threat involving multiple actors, with solutions requiring global efforts and policy change. Principles from behavioural economics could help to achieve a ‘recognition of necessity’ to change prescribing approaches. Importantly sepsis and AMS cannot be discussed in isolation, but should be portrayed as two sides of the same coin: in the framing of messages in the media and public health campaigns, and the alignment of organisational sepsis and AMS programmes

Balancing the risks to individual and society : a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals

CITATION: Krockow, E. M., et al. 2019. Balancing the risks to individual and society : a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. Journal of Hospital Infection, 101(4):428-439, doi:10.1016/j.jhin.2018.08.007.The original publication is available at https://www.sciencedirect.comBackground: Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. Aim: To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. Methods: A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. Findings: The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers’ behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. Conclusions: When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.https://www.sciencedirect.com/science/article/pii/S0195670118304183Publisher's versio

Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals.

BACKGROUND: Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. AIM: To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. METHODS: A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. FINDINGS: The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. CONCLUSIONS: When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice

Optimising antibiotic prescribing: Collective approaches to managing a common-pool resource.

BACKGROUND: Antimicrobial resistance (AMR) is one of the greatest threats in 21st century medicine. AMR has been characterised as a social dilemma. A familiar version describes the situation in which a collective resource (in this case, antibiotic efficacy) is exhausted due to over-exploitation. The dilemma arises because individuals are motivated to maximise individual payoffs, although the collective outcome is worse if all act in this way. OBJECTIVES: We aim to outline the implications for antimicrobial stewardship of characterising antibiotic overuse as a social dilemma. SOURCES: We conducted a narrative review of the literature on interventions to promote the conservation of resources in social dilemmas. CONTENT: The social dilemma of antibiotic over-use is complicated by the lack of visibility and imminence of AMR, a loose coupling between individual actions and the outcome of AMR, and the agency relationships inherent in the prescriber role. We identify seven strategies for shifting prescriber behaviour and promoting a focus on the collectively desirable outcome of conservation of antibiotic efficacy: (1) establish clearly defined boundaries and access rights; (2) raise the visibility and imminence of the problem; (3) enable collective choice arrangements; (4) conduct behaviour-based monitoring; (5) use social and reputational incentives and sanctions; (6) address misalignment of goals and incentives; and (7) provide conflict resolution mechanisms. IMPLICATIONS: We conclude that this theoretic analysis of antibiotic stewardship could make the problem of optimising antibiotic prescribing more tractable, providing a theory base for intervention development