Post on 13-Oct-2018
transcript
Influencing Antibiotic Prescribing Behavior: Outpatient Practices
Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria
September 13, 2017
Jeffrey A. Linder, MD, MPH, FACPProfessor of Medicine and Chief
Division of General Internal Medicine and GeriatricsNorthwestern University Feinberg School of Medicine
jlinder@northwestern.edu @jeffreylinder
Take Home Points• Doctors are people too• Doctoring is an emotional, social activity• Diagnostics are not the answer
• Behavioral principles− Decision fatigue− Partitioning − Pre-commitment− Accountable justifications− Peer comparison
Changing Behavior
• Limited success of prior interventions
Changing Behavior
• Limited success of prior interventions
• Implicit model: clinicians reflective, rational, and deliberate− “Educate” and “remind” interventions
Changing Behavior
• Limited success of prior interventions
• Implicit model: clinicians reflective, rational, and deliberate− “Educate” and “remind” interventions
• Behavioral model: decisions fast, automatic, influenced by emotion and social factors− Use cognitive biases− Appeal to clinician self-image− Consider social motivation
Imbalance in Factors Related to Antibiotic Prescribing
Mehrotra and Linder. JAMA Intern Med 2016
Factors Driving Antibiotic Prescribing: Immediate and Emotionally
Salient
• Bellief that a patient wants antibiotics
• Perception that it is easier and quicker to prescriibe antibiotics
than explain why they are unnecessary
• Habit
• Worry about serious complications and "just to be safe" mentallity
Factors Deterring Antibiotic Prescribing: More Remote and Less
Emotionally Salient
• Risks of adverse reactions and drug interactions
• Recognizing the need for antibiotic stewardshiip
• Desire to deter llow-value care and decrease unnecessary health
care spending
• Prefer to follow guidelines
l\.'1 Northwestern Medicine· Feinberg School of Medicine
Antibiotic Prescribing by Hour of the Day
Linder. JAMA Intern Med 2014
Nudging Physician Prescription Decisions by Partitioning the Order Set: Results of a Vignette-Based Study
David Tannenbaum, PhD 1, Jason N. Doctor, PhD2, Stephen D. Perse/1, MD, MPf--13,
Mark W. Friedberg, MD, MPp4-5-8
, Daniella Meeker, PhD6, Elisha M. Friesema, BA3 ,
Noah J. Goldstein, PhD7 , Jeffrey A. Linder, MD, MPf-f-8, and Craig R. Fox, PhD7
1 UCLA Anderson School of Management, Los Angeles, CA, USA; 2Leonard D. Schaeffer Center for Health Policy and Economics, University of
Southern California, Los Angeles, CA, USA; 3Division of General Internal Medicine and Geriatrics, Center for Healthcare Studies, Feinberg School of 4 5 6Medicine, Northwestern University, Chicago, IL, USA; RAND, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of
7Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; UCLA Anderson School of Management,
Department of Psychology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; 8Division of General Medicine and Primary Care,
Brigham and Women's Hospital, Boston, MA, USA.
l\.'1 Northwestern Medicine· Feinberg School of Medicine
Partitioning
Acute Bronchitis OTC medications grouped Of the drug choices below, please indicate which drugs you would choose in treating this patient. You may select up to three options.
o albuterol inhaler
o an antibiotic of your choice
o robitussin with codeine
o tes alon perles
Over-the-counter drugs: D cough lozenge o cough spray o cough syrup
l\'1 Northwestern Medicine· Feinberg School of Medicine
Partitioning
Acute Bronchitis Prescription medications grouped
perles
• 84 primary care clinicians
• 7 vignettes
• Randomized
− Prescription meds grouped
− Broader-spectrum grouped
− Vignette order
− Positioning of grouped items
• 84 primary care clinicians
• 7 vignettes
• Randomized
− Prescription meds grouped
− Broader-spectrum grouped
− Vignette order
− Positioning of grouped items
• Overall, 12% decrease in choosing aggressive treatment when grouped
Safe Antibiotic Use: A Letter From Your Medical Group
Dear Patient,
Al.1ilibiatics, lileepellidllin,.nghhnfect:io11sdue ro b.act::--riam.atcan =e som<eserioos
illi�. Bntlhese med:cines can =ise stdeeifero lilie skm:�, comi-iea. ar-yeast .
mfectjo1,s, rf }utn'5}'lnptnmsare froma .:.ius. §atamlnatlrom ba<Jtetfa,ya<1.-.ou
betta-wilh,111an1Jbi:oticand yauGJl!J: �getme,se bacl stdeeifect5.
.Al11i:biatiesa.:oo ma],,. bacta-iamm.,.resistrnttothem.. 'lbisoc.an rml;elimu-ein.'i;,doom..
h.a.i'Oa"toneat. 'I1ns RF-ai.tstha,antih:otics mig}ltootwm½oTAnBl yon reily:ne£,::I them, Bec.atL<e afmis.itis.iulpOltai.lttha!}'XI onty·u:sean e,ut:ibiotii=1•,het1itis
11ece2.aiyto traal!}'Oll.ll'illness.
Howcan yonhelp?· Cm;m]yfu'Jow}utn' dbmor's u1stt't11:ti.a!1.!c. He orshe.-.1 tE.l yaaif
}'XI moulil01·shauldnattilia ,mtibiotics;
\'�11et1 }'XI have amugp. sa,-etbroa.t 01•,othet• i!luess,. yaur,dactm·wi!lhelp}Ouselect
the bestpossib!ell-ea'imffit!;, lf.a11antlluioll-::•Amtlddo111a11?haim� §DDd.}Otn"
doo!nr-,�ille,plaiu tlris1D ym� mulm.rj' afferothe r t>eatt1,e1rtsmatare hett:: .... fu".ymL
YClln' hea:.'this·.eyiu,portaittro us. Asyaur,dadn,,s,""' jll'OluisetD 11-ea!}'Uln'i:.lness in . .the bestwio/pas.siblB Wearealso,dedicateclto :;i,,,:ix\ojll-eslcrih�igantihlotie;when
thej' <1l'e lilr,il:yro db moreh.aianin.an �
El Uso Seguro de Antibioticos: Una Carta de SU Grupo Medico,
IEst:imado Pacieute:
Queremo.s. oou,p,al1il"i.nf01miar:iotl in,poffillt�· 0011 usmdsobre as " 1tb1:i::5ti<ios,
Lo:s aim'bi6tioo.s == .la peniclina .3.'Jll.Oall iammbatir inf.ero:o:ns deb[do a l:>a.ct€riais ,que pueden camar serias. enf.ermechdes, Pero "5la6 med:rinas ta:mbien
-·enen efE!Jto:s seC11.11.1dariaG. 001110 erupcfans de la.p:el, di:arraa,. o inf.ero:ons par
ho11gos de leva.dura, Si sm sintomas sa11 debidos a ,m vinis y no pm· m,a bacteria,
nose mejarai.-a oo:n tm an1lbio.;ro, yus.!ecl a.tin puecle o:btEuei·estos. efuctos
secmid.n,;os. 110 de-,eab.es.
Lo:s aim'boi6tioo.s tarnbieri pu::-deuha.cE-r ba.ctE-rn mas t-e.sistente a e� Esto hara
qtte imeccianes en el fnmro sean mas dmci!es de ma.tar. Eso s�ca que os ,mtih:0000.s 1mtl'abaja,•.i,1 auaudo t�ted6 en 1'El.'l!:dad necesitall. q · e fuil.ciane-n. Par.
estQ. esimp01t.antequel.lstBdsolou,,,em1an1lbiotirocuai.i.do ses>11eces<1rioparasu
e11.'eiu1.edad
·Como puede m�il .3.'jltdar? Sig,. i.mlica.ciones cle su doobm: El o <'Ila le dira si
debe o 110tallla.J' ant:i'biotiem.
Cnando ·=,! tenga ,ma tos, ga:i•ganta imta.d.\, uotra etl"et·m.-eda.<l, s1.1 doctor le
:;rfl1dara.a esm,ger el mejar lrata:miento paGilile. Si m1 "1�1iib:6ti<io ham, mas dano
qt1e bi'en, su doct:ar- le e,qi�=i es,to y, · vez le ,afi'E<E'a otroG t1.·.tt.u11:e-1lbY.; que seait
mEjDrpara usted1
Sa s.alncl e. in,po1tr<t1� para no_sotrns. Gama sus. doct:ares, 110S0tro.s. Jll'OlrretEn,as.tratarsn e11."em1.edad eularn-ejor111aJ.1era pos'J .e. Thm'bien 110S oo:mp1'0111etemas a
evmru·,.,.,.,tar antib:iotiros •Cli1ll!lda sean pmbal:,les de hace,, Mis clai10 qne· b:e-1�
Si ·e11e cua1qwei·p�gi.mta,, p1-egirittele a s1.1 doCl!OJ;. en,"e1"111.e1-a, o fai·rnacemiro.
Atenumeut-e,
Public Commitment: Results
0%10%20%30%40%50%60%
Baseline InterventionAntib
iotic
Pre
scrib
ing
Rat
e
Control Poster
Adjusted difference-in-differences: -20% (-6% to -33%)
CDC Replications: IDPH & NYSDH
CDC Core Elements Outpatient Antibiotic Stewardship (2017)
EU Draft Guidelines for Antibiotic Stewardship
BEARI: The Behavioral Economics/Acute Respiratory Infection Trial
Specific Aim
• To evaluate 3 behavioral interventions to reduce inappropriate antibiotic prescribing for acute respiratory infections
−3 health systems using 3 different EHRs
Interventions
1. Suggested Alternatives
2. Accountable Justification
3. Peer Comparison
Intervention 2: Accountable Justification
Patient has asthma
Intervention 3: Peer Comparison
Intervention 3: Peer Comparison
“You are a Top Performer”You are in the top 10% of clinicians. You wrote 0 prescriptions out of 21 acute respiratory infection cases that did not warrant antibiotics.
Intervention 3: Peer Comparison
“You are a Top Performer”You are in the top 10% of clinicians. You wrote 0 prescriptions out of 21 acute respiratory infection cases that did not warrant antibiotics.
“You are not a Top Performer”Your inappropriate antibiotic prescribing rate is 15%. Top performers' rate is 0%. You wrote 3 prescriptions out of 20 acute respiratory infection cases that did not warrant antibiotics.
Main Results: Accountable Justification
-7% p < .001
Main Results: Peer Comparison
-5% p = <.001
Diagnostics are Not the Answer
Imbalance in Factors Related to Antibiotic Prescribing
Factors Driving Antibiotic Prescribing: Immediate and Emotionally
Salient
• Belief that a patient wants antibioticsl• Perception that it is easier and quicker to prescriibe antibiotics
than explain why they are unnecessary • Habit • Worry about serious complications and "just to be safe" mentalityl
Factors Deterring Antibiotic Prescribing: More Remote and Less
Emotionally Salient
• Risks of adverse reactions and drug interactions • Recognizing the need for antibiotic stewardshiip • Desire to deter low-value care and decrease unnecessary healthl
care spending • Prefer to follow guidelines
l\.'1 Northwestern Medicine· Mehrotra and Linder. JAMA Intern Med 2016 Feinberg School of Medicine
Summary: Behavioral Interventions• Doctors are people too• Doctoring is an emotional, social activity• Diagnostics are not the answer
• Behavioral principles− Decision fatigue− Partitioning − Pre-commitment− Accountable justifications− Peer comparison
Thank YouQuestions? Conversation?
jlinder@northwestern.edu @jeffreylinder
References
1. Mehrotra A, Linder JA. Tipping the balance toward fewer antibiotics. JAMA Intern Med. 2016;176(11):1649-1650.
2. Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med. 2014;174(12):2029-2031
3. Tannenbaum D, Doctor JN, Persell SD, et al. Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. J Gen Intern Med. 2015;30(3):298-304.
4. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med. 2014;174(3):425-431.
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):562-570.