Nudging physician behavior on antibiotic orders

Part of the problem of antibiotic resistance involves physicians’ habits. Doctors are used to prescribing antibiotics in certain situations, even when they may be inappropriate or when alternatives may be best. However, they may be susceptible to “nudges”, even if health care organization policies don’t formally restrict their choices. Former White House regulatory policy guru Cass Sunstein has written several books on this concept.

In March 2015, MD/PhD student Kira Newman and colleagues published a study in Journal of General Internal Medicine that has some bearing on this idea, although it doesn’t address antibiotic resistance directly:

Yelp for Prescribers: a Quasi-Experimental Study of Providing Antibiotic Cost Data and Prescription of High-Cost Antibiotics in an Academic and Tertiary Care Hospital.

The authors describe a shift involving the Emory University hospital electronic health record and order entry system. When a patient has systemic or urinary tract bacterial infection, the system shows a table of antibiotic sensitivity data alongside blood or urine culture results.

Beginning in May 2010, cost category data for antibiotics were added. Explicit numbers were not included – too complicated. Instead, the information was coded in terms of $ to $$$$. For the year after the change, the authors report a 31 percent reduction in average cost per unit of antibiotics prescribed. They conclude:

Many tools have been developed to reduce inappropriate antibiotic prescribing. In general, they have been successful at reducing the incidence of negative side effects of excessive or suboptimal antibiotic prescribing, such as C. difficile infection, colonization with antibiotic-resistant organisms, and mortality. The goal of our intervention, however, was purely to reduce cost without negatively impacting patient care… Despite its simplicity, the intervention was associated with decreases in antibiotic costs, supporting existing literature on the power of “nudges” in improving medical care.

Note: Newman is now researching norovirus. The co-authors were infectious disease specialist Jay Varkey, IT expert Justin Rykowski and Arun Mohan, previously medical director of care coordination at Emory Healthcare and now at ApolloMD.

Posted on by Quinn Eastman in Uncategorized 1 Comment

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Quinn Eastman

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