Displaying poster-sized commitment letters in the exam room to encourage proper antibiotic prescribing decreased inappropriate uses for acute respiratory infections, a study found.
Researchers set the study during a 1-year flu cycle. Prescribing habits were examined during a baseline period of three-quarters of the year, and then during an intervention period, when the poster was displayed during the peak of cold and flu season. The poster-sized commitment letters featured text about a commitment to avoid inappropriate prescribing for acute respiratory infections, and the clinicians’ photos and signatures, to hang in examination rooms for 12 weeks at 5 outpatient primary care clinics in Los Angeles.
Prescribers included 11 physicians and 3 nurse practitioners. A total of 954 adults had visits; 449 patients were treated by clinicians randomized to rooms with a posted commitment letter (335 in the baseline period, 114 in the intervention period) and 505 patients were treated by clinicians randomized to control rooms. (384 baseline, 121 intervention).
Results appeared online first at JAMA Internal Medicine.
Baseline rates were 43.5% for control rooms and 42.8% for poster rooms. During the intervention period of peak cold and flu season, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% when the poster was displayed, a nearly 20% absolute reduction in inappropriate antibiotic prescribing rate relative to control (P=0.02).
Researchers noted that the method was simple, low-cost intervention that had an effect comparable to costlier, more intensive quality-improvement efforts. Researchers wrote, “Our results show that active engagement in the form of public commitment need not involve extensive demands on provider time.”
An editorial compared the intervention to judo, a gentle redirection of intent relying on the concept of “public commitment” rather than an overpowering one.
“The authors developed a novel intervention that was based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescriptions,” the editorialist wrote. “Rather than direct confrontation with the force of education or nagging, they sought a gentler ‘nudging’ approach that worked harmoniously with the underlying psychology of both patient and clinician.”