Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.
OBJECTIVE
"Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice.


OBJECTIVE
To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs).


METHODS
Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention).


METHODS
The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs.


METHODS
Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status.


RESULTS
Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time.


CONCLUSIONS
Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.


BACKGROUND
clinicaltrials.gov identifier: NCT01767064.
RAND Corporation, Santa Monica, California.
Daniella
D
Meeker
Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles.
Tara K
TK
Knight
RAND Corporation, Boston, Massachusetts4Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts.
Mark W
MW
Friedberg
Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts.
Jeffrey A
JA
Linder
Anderson School of Management, University of California, Los Angeles.
Noah J
NJ
Goldstein
Anderson School of Management, University of California, Los Angeles.
Craig R
CR
Fox
COPE Health Solutions, Los Angeles, California.
Alan
A
Rothfeld
QueensCare Family Clinics, Los Angeles, California.
Guillermo
G
Diaz
Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles.
Jason N
JN
Doctor
D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D011307:Drug Prescriptions; D019983:Guideline Adherence; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control*; D007239:Infections / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care
D000900:Anti-Bacterial Agents