Nudging Guideline-Concordant Antibiotic Prescribing: A Randomized Trial facilitated by Prof Chris Del Mar

Journal Club Summary

Nudging Guideline-Concordant Antibiotic Prescribing: A Randomized Trial

12 February 2014

Facilitated by Professor Chris Del Mar

Background

Despite published guidelines and years of clinical interventions, inappropriate prescription of antibiotics for acute respiratory infections (ARI) is still widespread. Simple, inexpensive and effective measures to reduce antibiotic use and combat antibiotic resistance in the community are highly sought after.

Paper presented

Meeker et al.1 investigated the effect of displaying poster-sized letters in doctor’s examination rooms (stating the doctor’s commitment to avoid antibiotic use) on antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses. This type of intervention is a behavioural “nudge”, taking advantage of the clinicians’ desire to be consistent with their public commitment when it comes to treatment choices. The study timeframe included a complete 1-year season cycle of acute respiratory infections, with a three-quarter baseline period followed by poster implementation during peak cold and flu season (12-weeks).  A randomized trial was carried out in 5 outpatient primary care clinics in Los Angeles, California, comparing poster display (449 patients) vs standard practice control (505 patients).

The results and author’s main conclusions were:

  • During the intervention period, inappropriate prescribing rates decreased from the baseline rate of 42.8% to 33.7% in the commitment letter group but increased from 43.5% to 52.7% in the control group.
  • When controlling for baseline prescription rates, the posted commitment letter resulted in a 19.7 absolute percentage reduction in appropriate antibiotic prescribing rate relative to control.
  • Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs.

Discussion

The study uses a classification of antibiotic-inappropriate and antibiotic-appropriate ARI diagnoses (Table 1 in the paper). We agreed that this classification sets the bar very low (a number of conditions were categorized into the antibiotic-appropriate diagnoses group for which antibiotics would not normally be prescribed in Australia).

We considered the significance of the main result. The prescription rate in the intervention group went down by 10% but in the control group, it increased by 10%. Might this reflect a rather large margin of error, and the results would simply lie within that error? Or, an alternative explanation is that this decrease was superimposed on an increase expected from a change in season.

An important discussion point was whether the aim of the study was really a doctor or patient intervention. One sentence in the discussion indicates that it was intended as a doctor intervention. However patients’ responses might have contributed to the success of the intervention. There is no record of whether the patients randomized to the poster group actually saw and read it. The paper also lacks important details on how the intervention was delivered. Did the researchers just distribute posters in community practices or was there any education? We speculate that the intervention might have been an educational intervention aimed at doctors, but this was not clear from the paper.

Another point that was made is that this study only had a 12-week intervention period. It remains to be determined how sustainable such an intervention would be over longer periods of time.

The discussion mentions shared decision making (SDM) but the wording in the commitment letter says “Carefully follow your doctor’s instructions. He or she will tell you if you should or should not take Antibiotics”. We discussed what would be appropriate wording for a SDM poster and came with something along the lines of “Sometimes antibiotics are appropriate, sometimes they are not. We would like to help you decide.” However, a shared decision making approach is not just a “nudge” but rather a more intensive education.

The NPS has considered this type of intervention and we discussed how feasible this would be in Australia. It was suggested that the best thing might be to pilot such an intervention in a few group practices, then get qualitative feedback. It might also be better to display a commitment poster in the waiting room of a group practice, rather than the doctor’s examination room. Concerns were raised that GPs wouldn’t like this sort of commitment, because they would be afraid of losing “customers” to another practice due to such an intervention.  One way to counteract this would be to “convert” an entire Division, but this may prove impossible as doctors often prefer to act independently.

Reference:

  1. Meeker D. et al. (2014). Nudging Guideline-Concordant Antibiotic Prescribing: A Randomized Clinical Trial. JAMA Intern Med Jan 27. doi: 10.1001/jamainternmed.2013.14191.

Summary provided by Michele Weber

To read the article, click on the following link:

Meeker 14 RCT ABs posters (2)