Which intervention changed docs’ antibiotic prescribing?

prescription pad doctor

American researchers trialed three interventions to reduce inappropriate antibiotic prescribing… and two helped significantly

Jason N. Doctor, of the University of Southern California, Los Angeles, looked at how three behavioural interventions could help reduce antibiotic resistance related to inappropriate prescribing by doctors.

The three interventions were suggesting alternative to antibiotics for respiratory illnesses; making doctors accountable by making them record their reason for prescribing antibiotics; and peer comparison.

The interventions were randomised and 47 primary care practices in Boston and Los Angeles enrolled 248 clinicians to receive between zero and three interventions for 18 months.

All the participating clinicians were given education on antibiotic prescribing guidelines. Baseline prescribing rates were noted for inappropriate prescribing of antibiotics to treat nonspecific upper respiratory tract infections, acute bronchitis, and influenza.

Dr Doctor then examined the persistence of effects 12 months after the interventions were ceased.

There were 14,753 visits for antibiotic-inappropriate acute respiratory infections during the baseline period, 16,959 during the intervention period, and 7,489 during the postintervention period.

“During the postintervention period, the rate of inappropriate antibiotic prescribing decreased in control clinics from 14.2% to 11.8% (absolute difference, −2.4%); increased from 7.4% to 8.8% (absolute difference, 1.4%) for suggested alternatives (difference-in-differences, 3.8% [95% CI, −10.3% to 17.9%]; P = .55); increased from 6.1%to 10.2% (absolute difference, 4.1%) for accountable justification (difference-in-differences, 6.5 [95% CI, 4.2% to 8.8%]; P < .001); and increased from 4.8% to 6.3% (absolute difference, 1.5%) for peer comparison (difference-in-differences, 3.9% [95% CI, 1.1% to 6.7%]; P < .005),” the authors write.

“During the postintervention period, peer comparison remained lower than control (P < .001; 1-tailed test), whereas accountable justification was not different from control (P = .99; 1-tailed test).

“In the study, accountable justification and peer comparison significantly reduced inappropriate antibiotic prescribing at the end of the intervention period,” the authors write.

Limitations of the study are that it only included volunteering clinicians from selected practices, and the postintervention follow-up was only 12 months.

“These findings suggest that institutions exploring behavioral interventions to influence clinician decision-making should consider applying them long-term,” the authors write.

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  1. vixeyv

    Good ideas… how can we implement this type of intervention in Australia?

  2. Alison Claxton

    Sorry? Maybe it’s just me. Perhaps ‘inappropriate’ has been used in the paragraph quoting the statistics for the results rather than ‘ appropriate’?? I am struggling to see how significantly INCREASED rates of inappropriate prescribing are convincing us that interventions were successful….

    • Jarrod McMaugh

      It’s a comparison between three types of intervention in inapropriate prescribing.

      Basically, the first was successful in reduce inapropriate prescribing, while the other two seem to have increased it.

      Therefore the first intervention is appropriate, while the other two are not.

      • Alison Claxton

        Not quite that simple. I understand what the statistics are saying:
        12 months after the interventions were stopped, ALL the rates of inappropriate prescribing were actually worse than control, but peer comparison was ‘least worst’. Unfortunately they do not result in long lasting behaviour change, compared to just educating Drs on the prescribing guidelines. 2/3 of these interventions were effective, but need to be continued on.
        I realise now my problem is actually with the title and construction of the AJP news article. The letter referred to is about persistence of effect, not the original interventions as the title suggests. The section that states that two interventions were effective comes from early in the letter about the intervention period and does not belong in a discussion following the statistics, that do not support those statements. That’s why the article is confusing.

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