The health implications of too much antibiotic use are well known and include increases in rates of adverse drug events and rising health care costs; even more worrisome is the proliferation of antibiotic-resistant bacteria. Antibiotic agents, however, continue to be broadly, and often needlessly, prescribed. Traditional efforts to lower rates of inappropriate antibiotic prescription have included education of health care providers and patients and disruptive measures, but results have been mixed. The authors of a recent study wondered whether behavioral approaches might have a greater impact, so they studied behavioral interventions that “gently nudge” primary care physicians in the desired direction while preserving their freedom of choice.
The authors recruited 47 primary care practices in three health care systems in Massachusetts and Southern California. They focused their efforts on three interventions that were triggered by a prescription for an acute respiratory infection: suggested alternatives, an alert that popped up in a patient's electronic health record (EHR) suggesting alternate treatments; accountable justification, an EHR-based prompt requiring a prescriber to provide explanation in the EHR for the choice of medication; and peer comparison, in which providers were informed by e-mail whether they were “top performers” among those with the lowest rates of inappropriate antibiotic prescriptions.
What they found was that the two interventions with interpersonal (social) components—accountable justification and peer comparison—resulted in statistically significant reductions in inappropriate antibiotic prescribing. The suggested alternatives approach, which had no social component, did not lead to a significant reduction.
Of course, physicians are not the only dispensers of antibiotics. Mary Lou Manning, associate professor and infection-control specialist in the Jefferson College of Nursing at Thomas Jefferson University in Philadelphia, notes that NPs “are increasingly prescribers of antibiotics in primary care and thus can benefit from both types of behavioral interventions.” Most antibiotic prescriptions in the United States are for respiratory tract infections; in about half the cases, the medications have no effect on the illness for which they are prescribed. Statistics showing antibiotic use rising in winter months support these findings—most seasonal respiratory tract infections are viral. And although prescriptions for these agents are down overall among physicians, at least one recent study has shown them to be rising among NPs and physician assistants (PAs).
Manning notes, however, that the study of NPs and PAs focused on data that were more than five years old (2005 to 2010); since then the science has advanced, and many regional and national “antibiotic stewardship” initiatives have been implemented. Nevertheless, she says, “We must strive to provide a solid foundation during NP education related to the consequences of inappropriate antibiotic prescribing and the emergence of antibiotic resistance.”—Laura Wallis