Commitment posters encourage antibiotic stewardship

By Megan Brooks

NEW YORK (Reuters Health) – Hanging a poster in exam rooms displaying a doctor’s picture and commitment not to prescribe antibiotics for likely viral illness cut inappropriate prescribing during an influenza season in a randomized controlled trial.

“One of the advantages of this approach is that it is relatively easy to implement and administer in comparison to other clinical quality improvement programs,” Dr. Daniella Meeker of RAND Corporation in Santa Monica, California, who worked on the study, told Reuters Health in an email.

“Posters in exam rooms are commonly implemented as clinical guideline reminders. However, to our knowledge, this is the first time that such posters have included signatures, photos, and personal commitments to better care,” she said.

“The magnitude of our improvements were larger than what we would have expected from past studies of posters that don’t use commitment devices,” Dr. Meeker said.

The study, published online January 27 in JAMA Internal Medicine, involved five outpatient primary care clinics in Los Angeles. Seven doctors assigned to the intervention displayed commitment posters in their exam rooms for a 12-week period beginning in mid February 2012; an equal number of doctors made no change.

Commitment posters, written at an eighth grade reading level and displayed in English and Spanish, emphasized the doctor’s commitment to guidelines for appropriate antibiotic prescribing and explained why antibiotics were not appropriate in many cases. They included the doctor’s picture.

A total of 954 adults made visits for an acute respiratory infection during the study period. Of these, 449 patients were treated by doctors with posted commitment letters (335 in the baseline period, 114 in the intervention period), and 505 patients were treated by doctors who made no change (384 baseline, 121 intervention).

Inappropriate antibiotic prescribing rates at baseline were 43.5% for patients seeing doctors with commitment posters and 42.8% for control doctors.

During the intervention period, inappropriate prescribing rates decreased to 33.7% among doctors with commitment posters but increased to 52.7% among control doctors.

After controlling for baseline prescribing rates, the posted commitment letter resulted in a 19.7 absolute percentage reduction in the rate of inappropriate antibiotic prescribing, relative to control (p=0.02).

“When extrapolated to the entire United States, the posted-commitment letter intervention could eliminate 2.6 million unnecessary antibiotic prescriptions and save $70.4 million annually on drug costs alone,” the authors say.

There was no evidence of diagnostic shift away from antibiotic-inappropriate codes, and rates of appropriate antibiotic prescriptions did not diminish over time, they report.

The findings support social psychology research showing that individuals who make public commitments to specific behaviors are more likely to follow through with their expressed intention, the researchers say.

The commitment poster is “a new way to approach improvement in care quality,” Dr. Meeker said, “one that engages providers in personal and public commitments to better quality care. Given concerns of increased antibiotic resistance, improvements in antibiotic prescribing practice is a particularly important application.”

In an invited commentary, Dr. Brad Spellberg of Harbor-UCLA Medical Center in Los Angeles says the potential return on investment from this approach is “large.”

In addition, the intervention is easy to implement, requires no complex algorithms, no special technology, and no infrastructure or enforcement, he points out.

“How sustainable and how generalizable to other practice settings this gentle nudge approach is cannot be determined from the study, and it merits additional investigation,” Dr. Spellberg adds. Further research into the psychology that underlies inappropriate prescriptions may yield other new approaches to curb unnecessary prescribing.

“We also need to push into the clinic use of rapid diagnostics that empower providers to withhold antibiotics for viral infections and give the correct antibiotic for bacterial infections. Finally, policies that align the economics of self-interest with societal need, such as publicly reporting antibiotic use with modification of reimbursement based on the volume of antibiotics used (bonuses for low use, penalties for high use) would likely lead to sustained decreases in prescriptions,” Dr. Spellberg writes.

“We all bear responsibility to protect the public resource of antibiotic efficacy,” he concludes.

The study was supported by the National Institutes of Health and the National Institute on Aging.

http://www.newsdaily.com/health/44d2ed17177bcc6285ce8e561cb8a2e5/commitm...