A Behavioral Economics Multi-site Randomized Trial to Reduce Provider Antibiotic Overprescribing

Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Interventions that apply behavioral economic principles may be more effective than standard approaches (e.g., education) in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. In a large national randomized trial, we evaluated the effectiveness of three behavioral economic nudges to reduce ARI antibiotic overprescribing by primary care providers.

The application of Behavioral Economics to Improve the treatment of Acute Respiratory Infections (BEARI) Trial is a NIH funded multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three behavioral economics based interventions to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We have enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected data on over 26,000 patient visits. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. In this presentation, we report on the effectiveness of the three BEARI interventions in reducing inappropriate antibiotic prescribing.