Changing Clinician Behavior For Low-Value Care

I’ve reported in general terms several times regarding, essentially, the shameful rate of inappropriate antibiotic prescribing for upper respiratory infections.  Choosing Wisely says: stop!  However, aggregated data seems to indicate the effect of Choosing Wisely has been minimal.

This study, from JAMA, is a prospective, cluster-randomized trial of multiple interventions in primary care practices aimed at decreasing inappropriate antibiotic use.  All clinicians received education on inappropriate antibiotic prescribing.  Then, practices and participating clinicians were randomized either to electronic health record interventions of “alternative suggestion” or “accountable justification”, to peer comparisons, or combinations of all three.

The short answer: it all works.  The complicated answer: so did the control intervention.  The baseline rate of inappropriate antibiotic prescribing in the control practices was estimated at 37.1%.  This dropped to 24.0% in the post-intervention period, and reflected a roughly linear constant downward trend throughout the study period.  However, each different intervention, singly and in combination, resulted in a much more pronounced drop in inappropriate prescribing.  While inappropriate prescribing in the control practices had reached mid-teens by the end of the study period, each intervention group was approaching a floor-level in the single digits.  Regarding safety interventions, only one of the seven intervention practice clusters had a significantly higher 30-day revisit rate than control.

While this study describes an intervention for antibiotic prescribing, the basic principles are sound regarding all manner of change management.  Education, as a foundation, paired with decision-support and performance feedback, as shown here, is an effective strategy to influence behavioral change.  These findings are of critical importance as our new healthcare economy continues to mature from a fee-for-service free-for-all to a value-based care collaboration.

“Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices”