Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices
Authors: Daniella Meeker, Jeffrey A. Linder, Craig R. Fox, Mark W. Friedberg, Stephen D. Persell, Noah J. Goldstein, Tara K. Knight, Joel W. Hay, Jason N. Doctor
Journal: JAMA (2016)

<h3>Importance</h3> Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. <h3>Objective</h3> To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. <h3>Design, Setting, and Participants</h3> Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. <h3>Interventions</h3> Three behavioral interventions, implemented alone or in combination:<i>suggested alternatives</i>presented electronic order sets suggesting nonantibiotic treatments;<i>accountable justification</i>prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records;<i>peer comparison</i>sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates). <h3>Main Outcomes and Measures</h3> Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. <h3>Results</h3> There were 14 753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16 959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, −11.0%) for control practices; from 22.1% to 6.1% (absolute difference, −16.0%) for suggested alternatives (difference in differences, −5.0% [95% CI, −7.8% to 0.1%];<i>P</i> = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, −18.1%) for accountable justification (difference in differences, −7.0% [95% CI, −9.1% to −2.9%];<i>P</i> &lt; .001); and from 19.9% to 3.7% (absolute difference, −16.3%) for peer comparison (difference in differences, −5.2% [95% CI, −6.9% to −1.6%];<i>P</i> &lt; .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. <h3>Conclusions and Relevance</h3> Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. <h3>Trial Registration</h3> clinicaltrials.gov Identifier:NCT01454947