Healthcare News & Insights

‘Nudges’ cut back on unnecessary antibiotic use

Many hospitals are still struggling to get doctors to prescribe fewer antibiotics to patients. One recent study looked at how effective a few gentle “nudges” might be in helping doctors avoid unnecessary antibiotic use. 

ThinkstockPhotos-101858621The study, recently published in the Journal of the American Medical Association (JAMA), was designed to cut inappropriate antibiotic prescriptions for respiratory infections.

According to a press release about the study published on ScienceDaily, researchers from the University of Southern California used the term “nudge” to define an action designed to change a provider’s behavior without fear of punishment.

Ultimately, they wanted to see if providing doctors with positive reinforcement and friendly competition would reduce the likelihood they’d prescribe unnecessary antibiotics. So they tested the effectiveness of three positive nudges on prescribing patterns.

Gentle nudges toward change

The first nudge relied on the force of peer pressure, referred to in the study as “peer comparison.” After researchers gathered information about providers’ typical antibiotic prescribing habits, clinicians who participated in the study got an email message that showed them where they ranked in terms of administering prescriptions.

Doctors who wrote the fewest unnecessary prescriptions were deemed “top performers,” and they received an email message congratulating them. Those who had higher numbers of inappropriate antibiotic prescriptions were told exactly how many of their prescriptions weren’t necessary.

Similar peer comparison strategies have been effective in reducing energy and water use in consumers – and this trend continued with providers. At the beginning of the study period, 20% of prescriptions for antibiotics weren’t needed. The rates dropped to 4% by the time the study ended.

Researchers called the second nudge “accountable justification.” Whenever doctors documented that they ordered an antibiotic for a patient in their electronic health records (EHR) system, a prompt would pop up asking the doctor to justify the need for the drug. If the doctor didn’t have a particular reason for ordering the antibiotic, they were prompted to cancel the prescription.

If the doctor decided to write a justification in the EHR instead, the text would appear in the patient’s medical record. And all justifications could be seen by other clinicians.

The combination of having to defend the reason for the prescription, and knowing that it could be scrutinized by other providers, was effective in cutting excessive antibiotic use. In this phase of the study, the rate of administering antibiotics to patients with acute respiratory infections went from 23% to 5%.

A third nudge, referred to as “suggested alternatives,” was less effective in reducing antibiotic prescriptions. Here, every time a doctor noted in the EHR that a patient would receive an antibiotic for an upper respiratory infection, a pop-up message would appear on the screen suggesting an alternate treatment.

However, doctors didn’t respond as well to this nudge, as researchers said it had “no statistically significant effect” on antibiotic prescriptions.

Using this knowledge

The success achieved through most of these nudges shows that, when creating an antibiotic stewardship program focused on more responsible prescribing habits, using a carrot is more effective than a stick. Playing on doctors’ inner competitive nature, and recognizing them for a job well done, is key to changing their behavior for the better.

With that in mind, you may want to talk to your EHR vendor about the possibility of updating your system to keep better track of the antibiotic prescriptions your doctors order for patients. That way, you can pull data to compare providers’ prescriptions with each other – and recognize those who are already doing well.

To improve other providers’ performance, something as simple as adding a field to your EHR where doctors must explain why the prescription’s needed can help them break the habit of giving patients antibiotics without a clear rationale for the decision.

Bottom line: Positive reinforcement is your best bet in changing the culture surrounding your providers and unnecessary antibiotic prescribing, which can help rein in antibiotic-resistant superbugs.

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