title: Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial.
abstract: Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.
  
  
  
  Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.
  
  
  
  We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44-0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54-0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53-0.995).
  
  
  
  We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.
  
  
  
  ClinicalTrials.gov: NCT01454960 .
authors: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. spersell@nm.org.|Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. spersell@nm.org.
authors: Stephen D
authors: SD
authors: Persell
authors: USC Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa Street, Unit A, Los Angeles, CA, 90089-7273, USA.
authors: Jason N
authors: JN
authors: Doctor
authors: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, 1620 Tremont Street, BC-3-2X, Boston, MA, 02120, USA.|RAND, 20 Park Plaza, Suite 920, Boston, MA, 02116, USA.
authors: Mark W
authors: MW
authors: Friedberg
authors: USC Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa Street, Unit A, Los Angeles, CA, 90089-7273, USA.|RAND, 1776 Main St., Santa Monica, CA, 90401, USA.
authors: Daniella
authors: D
authors: Meeker
authors: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.|Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
authors: Elisha
authors: E
authors: Friesema
authors: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
authors: Andrew
authors: A
authors: Cooper
authors: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
authors: Ajay
authors: A
authors: Haryani
authors: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
authors: Dyanna L
authors: DL
authors: Gregory
authors: Department of Psychology, UCLA Anderson School of Management; David Geffen School of Medicine at UCLA, UCLA, 110 Westwood Plaza D-511, Los Angeles, CA, 90095, USA.
authors: Craig R
authors: CR
authors: Fox
authors: Department of Psychology, UCLA Anderson School of Management; David Geffen School of Medicine at UCLA, UCLA, 110 Westwood Plaza D-511, Los Angeles, CA, 90095, USA.
authors: Noah J
authors: NJ
authors: Goldstein
authors: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, 1620 Tremont Street, BC-3-2X, Boston, MA, 02120, USA.
authors: Jeffrey A
authors: JA
authors: Linder
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001519:Behavior; D003657:Decision Making; D020000:Decision Support Systems, Clinical; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control* / Q000706:statistics & numerical data; D007400:Interprofessional Relations; D008297:Male; D008875:Middle Aged; D010612:Pharyngitis / Q000188:drug therapy; D058007:Physicians, Primary Care / Q000193:education / Q000523:psychology / Q000592:standards; D010865:Pilot Projects; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D055656:Prescriptions / Q000592:standards / Q000706:statistics & numerical data; D012141:Respiratory Tract Infections / Q000188:drug therapy; D012852:Sinusitis / Q000188:drug therapy
chemical_list: D000900:Anti-Bacterial Agents
keywords: Acute respiratory infections; Antibiotics; Behavioral economics; Clinical decision support; Social psychology