Social pressure cuts antibiotic prescribing

Limiting inappropriate antibiotic prescribing is proving difficult. However, a new study from the US suggests that “socially motivated interventions” aimed at prescribers reduce inappropriate antibiotic prescribing for acute respiratory tract infections (ARTI).

The 248 clinicians at 47 primary care practices received education about antibiotic prescribing. The study then assessed three interventions, alone or combined:

  • Patient records automatically reminded prescribers that antibiotics are not generally indicated and suggested alternatives
  • The prescriber justified antibiotic use in a free text section visible in the records. If they did not enter text, “no justification given” appeared
  • A monthly email told clinicians in the decile with the lowest inappropriate prescribing rates that they were “top performers.” Other clinicians were told that they were “not a top performer” and their inappropriate prescriptions were compared with the best decile.

Antibiotic prescribing reduced in study

Among control practices, mean antibiotic prescribing decreased from 24.1 to 13.1 per cent between the start and end of the 18-month intervention, an absolute decline of 11.0 per cent. Suggested alternatives reduced antibiotic prescribing by 16 per cent from 22.1 to 6.1 per cent, although this was not statistically significant compared to controls.

Accountable justification reduced antibiotic prescribing by 18.1 per cent (from 23.2 to 5.2 per cent) and peer comparison by 16.3 per cent (from 19.9 to 3.7 per cent). Combining approaches showed neither synergy nor interference.

In control practices, 0.43 per cent of patients returned for possible bacterial infections within 30 days of visits for antibiotic-inappropriate and potentially appropriate ARTIs in which antibiotics were not prescribed. Significantly more patients in the accountable justification plus peer comparison group returned (1.41 per cent). No other group (including all three) showed a significantly higher rate.

The “socially motivated interventions” – accountable justification and peer comparison – significantly reduced inappropriate antibiotic prescribing. Suggested alternatives that lacked a social component had no significant effect. The benefits are additional to education and observation, both of which applied to the controls.

The authors of the research say the effects are “clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline.”

(JAMA 2016: 315; 562-570)

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