By Stephanie Hedt
Schaeffer Center experts Daniella Meeker, Jason Doctor, Joel Hay, Tara Knight and colleagues were recognized with the 2019 Behavioral Science & Policy Association (BSPA)’s Behavioral Best Publication Award for their 2016 Journal of the American Medical Association (JAMA) study on inappropriate antibiotic prescribing. The award recognizes research that advances rigorous application and development of social research into policy and practice to improve the quality of life for individuals and organizations. This year’s award evaluated published research between 2016 and 2018 across a wide-range of policy areas including financial decision-making, energy and the environment, education, justice and ethics, management and labor and health.
The study used novel social interventions to reduce inappropriate antibiotic prescribing. Recognizing that people often follow the lead of successful others, one intervention presented monthly information on individual performance along with that of persons who were successful at prescribing antibiotics judiciously. A second intervention, leveraged that people are careful to avoid acting in ways that engender reputational concerns. It required clinicians give a short ‘tweet length’ justification within the electronic health record explaining why antibiotics were being prescribed when guidelines recommended against it. The interventions were a radical departure from traditional decision support that gives reminders, alerts and educates clinicians with rational reasons for adhering to guidelines.
“This research is an outstanding example of the careful work that is need to assess the effectiveness of behavioral interventions to address significant public health issues,” said Paul Slovic, professor of psychology at the University of Oregon and founder and President of Decision Research. “By reducing the rate of inappropriate antibiotic prescribing by doctors, this paper highlights the impact of research in action.”
Each year over 200 leading behavioral scientists, executives, policymakers and journalists attend the BSPA Conference to explore the latest insights from behavioral sciences research. The conference focuses on how behavioral insights can enhance private and public-sector practice, helping bridge the divide between behavioral scientists and practitioners.
Reducing Inappropriate Antibiotic Prescribing is a National Priority
The CDC estimates that almost half of antibiotics prescribed for upper respiratory infections are inappropriate and unnecessary. While doctors know there are consequences for these bad prescriptions- both for the patient and society with the rise of antibiotic resistant bacteria- education, financial incentives, and punitive policies have had limited impact.
Doctor and his colleagues decided to take a different approach and use insights gained from behavioral sciences to nudge physician behavior.
In one intervention analyzed, clinicians received an email informing them of their ranking, from highest to lowest, for inappropriate prescriptions. Clinicians with the lowest rates were told they were “top performers” and were congratulated. This peer-comparison nudge prompted a 15 percentage point reduction in clinicians’ rates of inappropriate antibiotic prescribing, from 20 percent to nearly 4 percent.
A second intervention, accountable justification, required clinicians to justify the antibiotic prescription in the patient’s electronic chart. This written justification would be added to the chart and would be seen by other clinicians. This nudge resulted in an 18 percentage point drop, from 23 to 5 percent.
“Behavioral nudges have been used to change behavior in other areas for a while,” said Jason Doctor, director of health informatics at the Schaeffer Center. “What we showed is simple nudges can be effective in healthcare. In particular, they allow doctors to maintain independence over decision-making while nudging them towards best practices.”
If implemented across the country, the intervention could eliminate over 2.6 million unnecessary antibiotic prescriptions and save $70.4 million.
In the years since the study was published, public health officials, policymakers, and industry stakeholders have leveraged the findings to reduce inappropriate prescribing habits. The Centers for Disease Control and Prevention identified the nudge as a best practice in their campaign to reduce antibiotic use. In addition, other federal agencies, multiple state health departments, and even the United Kingdom’s behavioral science unit have implemented the intervention to improve prescribing.
Doctor has also led studies that tested other nudges and behavioral aspects of prescribing behavior including the impact of displaying a public poster, time of day and the order of choices in electronic medical records. Most recently, Doctor has looked at nudges to reduce opioid prescribing.
The study was funded by the 2009 American Recovery and Reinvestment Act through the National Institutes of Health/National Institute on Aging (RC4 AG039115) and Agency for Healthcare Research and Quality (R01 HS19913-01). Researchers also received technology support via another stimulus grant awarded to Lucila Ohno-Machado at the University of California-San Diego.
Meeker is an assistant professor of preventive medicine at Keck School of Medicine of USC. Doctor is the Norman Topping Chair in Medicine and Public Policy at the Price School of Public Policy. Hay is a professor at the USC School of Pharmacy and Knight is a program manager at the Schaeffer Center.
Other study co-authors were Craig Fox of University of California-Los Angeles; Mark Friedberg of Brigham and Women’s Hospital, Harvard Medical School and RAND Corp.; Stephen Persell of Northwestern University.
Chair, Department of Health Policy and Management
Director of Health Informatics, USC Schaeffer Center