Wednesday, January 29, 2014
QD: News Every Day--Poster-sized commitment to fewer antibiotics offers modest reduction for prescriptions
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.”
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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The Public Library of Science's open access materials include a blog.
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