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Am Fam Physician. 2016;93(12):1037

Clinical Question

Do behavioral interventions reduce rates of inappropriate antibiotic prescribing for acute respiratory tract infections in primary care?

Bottom Line

Requiring clinicians to justify antibiotic prescribing in the permanent electronic health record and to undergo periodic peer comparisons of prescribing rates are effective interventions for reducing inappropriate antibiotic prescribing for acute respiratory tract infections. Helpful reminders and suggested treatment alternatives do not reduce inappropriate prescribing rates. Information alone rarely changes behavior, but the desire to conform with our peers can be very persuasive. (Level of Evidence = 1b−)


Clinical guidelines encourage avoiding antibiotics for infections when treatment is of minimal, if any, benefit. However, inappropriate antibiotic prescribing for acute respiratory tract infections persists. These investigators invited 49 practices in Massachusetts and California (N = 243 clinicians) to receive various combinations of behavioral interventions aimed at reducing inappropriate antibiotic prescribing. The first intervention used automated alternative treatment suggestions when clinicians attempted to prescribe antibiotics for antibiotic-inappropriate diagnoses. A second intervention required clinicians to enter an antibiotic justification note that became a permanent part of the medical record. The third intervention distributed periodic e-mails to participating clinicians labeling them as either a “top performer” or “not a top performer” by comparing their antibiotic prescribing behavior with that of their peers.

Clinicians included internists (60%), nurse practitioners/physician assistants (19%), and family physicians (13%). The study excluded patients with chronic medical conditions that necessitate more frequent antibiotic prescriptions for acute respiratory tract infections (e.g., emphysema). Practices were randomized to receive zero, one, two, or all three interventions for 18 months, and no cases were lost to follow-up. Not surprisingly, the control group significantly decreased inappropriate antibiotic prescribing rates (11% absolute reduction) during the study period. This is known as the Hawthorne effect: changing your behavior because you know you are being observed. Both the accountable justification and peer comparison interventions significantly decreased antibiotic prescribing rates compared with the control group (−7.0% and −5.2%, respectively). However, the suggested alternatives intervention did not significantly reduce antibiotic prescribing rates compared with control. The latter result is disheartening but consistent with previous findings about influencing clinical decision making: Information alone rarely changes behavior. The most powerful influence continues to be peer pressure and the desire to conform.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (primary care)

Reference: MeekerDLinderJAFoxCRet alEffect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA2016;315(6):562–570.

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