Ways to reduce inappropriate Antibiotic Prescription Rates—Part I

In a study published last month in JAMA, “Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial” (http://jama.jamanetwork.com/article.aspx?articleid=2488307 ), Meeker et al. describe a set of interventions that aim to reduce inappropriate prescription of antibiotics by primary care physicians.

The study topic has cost and population health implications: in addition to the wasted cost of the drugs, inappropriate prescriptions lead bacteria to evolve faster to resist the drugs and in turn increase the infections that cannot be treated effectively and efficiently.

Study co-authors Fox, Linder and Doctor give a non-technical summary of the JAMA paper and related research in The New York Times on 27 March here.

The control group substantially reduced inappropriate prescription over the course of the experiment, so the statistical analysis assessed impacts beyond the control group’s reduction.

Two of the three interventions—“peer comparison” and “accountable justification”-- had statistically significant reductions beyond the reduction achieved by the control group. (I briefly reviewed the current debate about use of statistical significance here.)

While analysis of the experimental design and its implications for practice are important and related to these recent posts (here, here and here), I want to focus now on one intervention, the peer comparison.

Here’s the definition: researchers “sent monthly emails to clinicians that compared their antibiotic prescribing rates with those of ‘top performers’ (those with the lowest inappropriate prescribing rates.)” (from the abstract).

At the beginning of the antibiotic study, all physicians were reminded about standard clinical guidelines to treat respiratory ailments. They were prompted to think about their own and their peers’ prescribing practices. They also received an “injunctive norm” that stated the endorsement of the guidelines by professional societies and the CDC.

These common steps helped all physicians on average to reduce inappropriate prescriptions; indeed, the control group cut inappropriate use almost in half. The psychological premise of the peer comparison intervention is that reminders of one’s performance relative to top performers will provoke action to improve. If you are already a top performer, feedback about your performance will motivate you to keep doing what you’ve been doing.

In addition to the social psychology, the monthly email reminders in the peer comparison treatment kept the information and aim of the study “top of mind.”

The peer comparison intervention appears to be an example of “if you measure performance (and report it), you can improve performance.”

We just have to be careful not to believe that the study’s peer comparison intervention indicates “If you measure performance (and report it), you will improve performance.”

Measurement doesn't necessarily lead to improved performance, even in this experiment.

I’ll make the case in the next post.