Signed posters remind doctors to limit antibiotics

The researchers estimate that a simple intervention—a prominently displayed commitment letter—could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million in drug costs alone if extrapolated across the United States. (Credit: davidd/Flickr)

Physicians continue to prescribe antibiotics for colds, even though they won’t help the patient get better—a practice that results in millions of dollars in unnecessary health care costs annually in the United States and contributes to the problem of antibiotic-resistant bacteria.

In a recent study, researchers had physicians post a large letter about inappropriate antibiotic prescription in their exam rooms. The letter, displayed in both English and Spanish in Los Angeles clinics, had a picture of the physician and his/her signature, and explained the physician’s commitment to reducing inappropriate prescriptions for acute respiratory infections, such as the common cold.

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The researchers then looked at clinic records over the next three months, comparing rates of inappropriate antibiotic prescriptions to a control group that did not sign or post a public commitment poster.

“Most quality improvement efforts have used audits or pay-for-performance incentives to try to change what providers do, but they ignore social influences that affect all people, including physicians,” says senior author Jason Doctor, associate professor of clinical pharmacy and pharmaceutical economics and policy at the University of Southern California.

“Our study is the first to apply the principles of commitment and consistency to prescribing behavior and finds a simple, low-cost intervention that shows great promise in reducing inappropriate antibiotic prescription.”

The researchers estimate that a simple intervention—a prominently displayed commitment letter—could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million in drug costs alone if extrapolated across the United States.

Defensive’ prescribing

A signed commitment poster dramatically decreased unnecessary antibiotic prescriptions: among physicians who posted the letter, inappropriate antibiotic prescriptions fell nearly 10 percentage points, to 33.7 percent of total antibiotic prescriptions from 42.8 percent in the year before the study.

In contrast, inappropriate antibiotic prescriptions actually increased in the control group, who started with a similar 43.5 percent inappropriate prescription rate. Over the study period, the prescription of antibiotics in instances where they would not be effective rose to 52.7 percent among those who did not post a commitment poster.

Importantly, rates of appropriate antibiotic prescription did not change. There also was no evidence of changes to how illnesses or diagnoses were coded by clinicians.

“The findings from the study support the idea that clinicians are influenced by professional and social factors in patient care, and unlike some quality improvement interventions based upon financial incentives, we found no evidence that improvements were driven by changing documentation practices,” says lead author Daniella Meeker, a fellow at the USC Schaeffer Center for Health Policy and Economics. “This low-cost and easily scalable intervention has great potential to reduce inappropriate antibiotic prescribing.”

“This intervention is a unique addition to interventions that have decreased inappropriate antibiotic prescribing for respiratory infections. Most other interventions have been focused on reminders or education and this is a novel, low-cost approach,” says Jeffrey A. Linder, an expert in antibiotic prescribing at Brigham and Women’s Hospital and Harvard Medical School.

The study did not look at why physicians might be inclined to overprescribe antibiotics, but possible explanations from other research include patient demand and “defensive” prescribing.

“The results move beyond educational posters, showing how public commitments and active engagement can prompt greater personal motivation to perform a behavior, in this case reversing a tendency to prescribe antibiotics when they are not effective,” Doctor says.

Researchers at University of California, Los Angeles, COPE Health Solutions, and Queenscare Family Clinics were co-authors of the study, which was supported by the National Institute on Aging of the National Institutes of Health and published in JAMA Internal Medicine.

Source: USC