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Original Investigation |

Nudging Guideline-Concordant Antibiotic Prescribing:  A Randomized Clinical Trial

Daniella Meeker, PhD1; Tara K. Knight, PhD2; Mark W. Friedberg, MD, MPP3,4,5; Jeffrey A. Linder, MD, MPH4,5; Noah J. Goldstein, PhD6; Craig R. Fox, PhD6; Alan Rothfeld, MD7; Guillermo Diaz, MD8; Jason N. Doctor, PhD2
[+] Author Affiliations
1RAND Corporation, Santa Monica, California
2Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California, Los Angeles
3RAND Corporation, Boston, Massachusetts
4Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
5Harvard Medical School, Boston, Massachusetts
6Anderson School of Management, University of California, Los Angeles
7COPE Health Solutions, Los Angeles, California
8QueensCare Family Clinics, Los Angeles, California
JAMA Intern Med. 2014;174(3):425-431. doi:10.1001/jamainternmed.2013.14191.
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Importance  “Nudges” that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice.

Objective  To investigate the use of a behavioral “nudge” based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs).

Design, Setting, and Participants  Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention).

Interventions  The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs.

Main Outcomes and Measures  Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status.

Results  Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time.

Conclusions and Relevance  Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.

Trial Registration  clinicaltrials.gov identifier: NCT01767064

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A total of 14 clinicians completed the study, treating 954 patients.

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