Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

Flora Le, Mercer University College of Pharmacy

A review of eight studies evaluating antibiotic use and reconsultation rates showed that the use of information leaflets in general practice consultations reduced the number of antibiotic prescriptions and decreased the actual antibiotic use by patients and their intention to reconsult for future similar episodes of illness.  [1]

According to the Centers for Disease Control and Prevention (CDC), approximately 50% of antibiotic prescriptions written in the outpatient setting are unnecessary. Outpatient antibiotic stewardship uses clinical practice guidelines for common infections to help establish standards of care, focus quality improvement efforts, and improve patient outcomes to decrease antibiotic-resistant infections.  [2]

Title: Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices
Design Multisite, cluster, randomized clinical trial in Boston and Los Angeles; N= 14,753
Objective To assess effects of behavioral interventions and rates of inappropriate antibiotic prescribing during ambulatory visits for acute respiratory tract infections
Study Groups Three behavioral interventions, implemented alone or in combination: 1.) suggested alternatives in electronic order sets suggesting non-antibiotic treatments; 2.) accountable justification  prompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records; 3.) peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of the lowest inappropriate prescribing rates
Methods 248 enrolled clinicians were randomized to receive zero, one, two, or three interventions for 18 months and education on antibiotic prescribing guidelines.
Duration November 1, 2011 to April 1, 2014
Primary Outcome Measure Measuring the antibiotic prescribing rate for antibiotic-inappropriate acute respiratory tract infection visits and no concomitant reason for antibiotic prescribing
Baseline Characteristics Patient characteristics Overall Control

(n= 2,095)

Suggested alternatives

(n= 2,388)

Accountable justification

(n= 1,979)

Peer Comparison

(n= 1,620)

Suggested alternative + accountable justification

(n= 2,131)

Suggested alternative + peer comparison

(n= 2014)

Accountable justification + Peer comparison

(n= 2,240)

Suggested alt + accountable justification + peer comparison

(n= 2,492)

Age- yr. 48 49 48 53 47 50 48 49 43
Men 33% 35% 28% 42% 32% 29% 31% 34% 33%
White 87% 88% 86% 90% 85% 85% 86% 91% 84%
Black 5% 4% 5% 5% 6% 6% 8% 2% 5%
Asian 5% 4% 4% 3% 6% 7% 3% 4% 7%
Other/ unknown 3% 4% 5% 2% 3% 2% 3% 3% 4%
Hispanic/ Latino 32% 35% 30% 25% 26% 19% 41% 38% 37%
Results Mean antibiotic prescribing rates were 24.1% at intervention start and 13.1% at intervention month 18 for control practices; suggested alternatives: 22.1% to 6.1% (95% [CI]: 7.8% to 0.1%]; accountable justification: 23.2% to 5.2% (95% [CI]: 9.1% to 2.9%], p < 0.001); peer comparison: 19.9% to 3.7% (95% [CI]: 6.9% to 1.6%], p < 0.001)
Adverse Events Common Adverse Events: N/A
Serious Adverse Events: N/A
Percentage that Discontinued due to Adverse Events: N/A
Study Author Conclusions Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections.

The results from this study are consistent with prior studies indicating that behavioral interventions for physicians help to decrease the rate of inappropriate antibiotic prescriptions.  A limitation for this study would be that the study did not investigate harms caused by unnecessary antibiotic prescribing.   For future studies, a focus on investigating the harms caused by unnecessary antibiotic usage in patients can further strengthen the findings in this trial and the need for antibiotic stewardship.


  1. De Bont EGPM, Alink M, Falkenberg FCJ, Dinant G-J, Cals JWL. Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review. BMJ Open. 2015;5(6):e007612. doi:10.1136/bmjopen-2015-007612.
  2. Outpatient Antibiotic Stewardship. Centers for Disease Control and Prevention2015. Available at: http://www.cdc.gov/getsmart/community/improving-prescribing/outpatient-stewardship.html. Accessed February 28, 2016.
  3. Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care. 2008;46(8):847-62.
  4. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;(4):CD003539.
  5. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 2016;315(6):562-70.

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