Today’s Managing Health Care costs Number is 23,000
It’s hard to get physicians to stop overprescribing antibiotics. This is especially important because 23,000 people a year die of antibiotic resistant infections.
JAMApublished research early this month suggesting that two interventions can make a difference with volunteer academic primary care physicians – which is a huge deal since virtually no physician education or incentive intervention has previously seemed to make a difference.
The researchers randomized physicians by groups – and did “cluster” randomization where they used either no interventions (control group), or 1,2, or 3 interventions (experimental groups). That left 7 experimental groups; 3 got a single intervention, 3 got two intervention, and 1 got all three interventions. This allowed the researchers to ascertain whether the interventions interacted.
The two “behavioral economic” interventions, accountable justification (physicians who wanted to prescribe antibiotics had to list the reason why they didn’t follow the guidelines), and peer comparison (physicians were notified each month if they were in the top decile of performance), caused statistically significant decreases in inappropriate antibiotic use. The third, where the electronic health record suggested alternatives, was associated with a decrease in inappropriate antibiotic prescribing that was not statistically significant. The researchers checked to be sure that this didn’t represent coding changes, and they did chart reviews on patients who had followup visits within 30 days to see if there was harm from NOT prescribing antibiotics. There were some cases where patients clearly needed antibiotic treatment at the followup visits, although the record review didn’t clearly show the need at the initial visit.
This is heartening. Asking doctors to justify their off-guideline care, and telling them whether they are “top performers” can lead to more appropriate care.
I’m struck that the decrease in inappropriate antibiotic use was so high in the control group. All physicians got basic information about the importance of not overprescribing antibiotics – and this type of educational intervention has usually not worked. Here, in the control group, it did seem to work. I suspect that simply knowing that they were being observed changed the practices of the control physicians – making it clear that public reporting can be a good way to influence physician behavior too.
Since a small number of physicians are responsible for a large share of the inappropriate narcotic prescriptions that can lead patients into the downward spiral of opiate addiction, this approach should be tried for these medications as well. This study wasn’t easy or cheap to do, though. It took 36 months of data collection and payment of $300,000 to the participating physicians – as well as expensive logistics for the researchers.
JAMA e-published a follow-up article yesterday about public policy initiatives necessary to decrease overuse of antibiotics. The editorialists suggested public reporting, considering antibiotic stewardship in approval of new antibiotics, and better prescribing information. I’d add decreasing factory farm use of antibiotics as well.
Above is the time sequence for decrease in inappropriate antibiotic use in this study. You can see that the rate of inappropriate prescribing decreased steadily even before the intervention in all groups, and there was a larger drop in all three intervention groups. The difference was smaller in the “suggested alternative” group, and it didn’t reach statistical significance.
