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.