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. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1715-8) contains supplementary material, which is available to authorized users

Replication data for: Nudging physician prescription decisions by partitioning the order set: Results of a vignette-based study

BACKGROUND: Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can in- fluence provider decisions for better or worse. OBJECTIVE: The purpose of this study was to examine whether the grouping of menu items systematically af- fects prescribing practices among primary care providers. PARTICIPANTS: We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51 % response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting. DESIGN: The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symp- toms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications indi- vidually while g rouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition. MAIN MEASURES: The main outcome was provider treat- ment choice. For antibiotic-inappropriate vignettes, we cat- egorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics. KEY RESULTS: Across vignettes, there was an 11.5 per- centage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95% CI: 2.9 to 20.1%; p=.008). CONCLUSIONS: Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians'™ ability to prescribe what they believe is best for their patients

Additional file 1: of Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial

Table S1. Acute Respiratory Infection Diagnoses Related to Interventions and Outcomes Assessments. Table S2. Results of Clinician Randomization and the Secondary Outcome Potentially-Antibiotic-Appropriate ARI Diagnoses. Table S3. Results of Clinician Randomization and the Secondary Outcome Other ARI Diagnoses or Symptoms of Interest. Table S4. Results of Clinician Randomization and the Secondary Outcome All ARI Categories Combined. Table S5. Distribution of Safety Monitoring Events. (DOCX 27 kb