Interventions Reduce Inappropriate Antibiotic Prescribing in Primary Care Practices — Physician’s First Watch

Medical News |
February 10, 2016

Interventions Reduce Inappropriate Antibiotic Prescribing in Primary Care Practices

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

Two behavioral interventions can help reduce inappropriate antibiotic prescriptions for acute respiratory tract infections at primary care practices, a JAMA study suggests.

Nearly 50 practices in Boston and Southern California were randomized to the following interventions (alone or in combination) for 18 months:

  • Suggested alternatives: An EHR-based intervention in which acute respiratory tract infection diagnoses prompted a pop-up message stating "antibiotics are not generally indicated" and then listed treatment alternatives.

  • Accountable justification: Clinicians seeking to prescribe antibiotics were prompted by their EHR to write a justification for the prescription; the justification then appeared in the patient's medical record.

  • Peer comparison: Participants received monthly emails in which their rate of inappropriate prescribing was ranked against other participants' rates.

After adjustment for co-occurring interventions, accountable justification and peer comparison each led to significantly greater reductions in inappropriate antibiotic prescribing relative to no intervention. From the pre-intervention period to the intervention's end, the rate of inappropriate prescribing fell from 23% to 5% with accountable justification, and from 20% to 4% with peer comparison (vs. from 24% to 13% with control).

Dr. Thomas Schwenk of NEJM Journal Watch General Medicine commented: "The baseline rate of inappropriate prescribing was already low compared with national data and declined over the 18-month run-in period, suggesting that these results may not generalize to other physician groups. However, interventions that focus on physician professional pride and performance appear to have promise, and should be easily implemented in any practice with an EHR."

Reader Comments (3)

Javier Gómez, MD Physician, Infectious Disease

These interventions are geared towards the people who have to deal with the problem, not the problem itself. Most doctors who prescribe antibiotics for things they wouldn't normally do it, do so because of patient pressure, fully aware is not the right medical decision. Patients come to the appt wanting that, if you don't give it they go to somebody else, get abx, and get better (as they were going to anyways even without it) and then they don't want to go back to you. Or you explain and hold abx during a visit, then they call and insist after a couple of days, you end up giving them anyways. This is the majority of the cases unfortunately. These interventions mentioned here try to tell the doctor "are you sure this is needed?". We already know the answer: No, it's not. Which is irrelevant. Just look at what they do at the ER's: Cough=zpak+medrol pack+tussinex The best thing would be to do campaigns to make patients aware that antibiotics are not the answer for everything. It's not our fault, really. But even if a patient does not show up for a follow up after a hospital visit, it counts against the physician. Our salaries are tied to patient outcomes. Everything is the physicians fault

Kathleen Stefek Nurse/NP/PA, Family Medicine/General Practice, FQHC

I agree that the EHR should never replace clinical judgement of the provider. However, it might make you think twice before giving in to the patient who is pressuring you for an antibiotic that is not clinically necessary or even just to ask yourself why you feel this is appropriate for this particular patient at this time. Too much antibiotic resistance not to take this seriously

William DeMedio MD Physician, Family Medicine/General Practice, Private

I have generally found that the threat of an EMR causing a medical mistake is greater than pencil and paper. In addition, I see no good outcomes data attributable to the use of the EMR on actual morbidity and mortality in primary care for the past 20 years.

Having an EMR suggest medical advice when they are not proven to be beneficial is foolhardy at best.Software Decision making tools should not be foisted on the physician.

The incidence of PTA, Mastoiditis, Invasive OM resulting in meningitis, and other serious bacterial complications have declined dramatically in the past 100 years due to the purported "inappropriate use" of antibiotics. Perhaps with the new paradigm using algorithms to "nudge" the "health care provider" into a new mode of practice will bring these diseases back, and the ENT and Neurosurgeons will have a field day, along with the people involved in the long term care of young folks.

Sometimes nearsightedness can be a fatal illness.

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