A tiny study of physician antibiotic prescribing practices, discussed in a recent issue of JAMA, has set the health blogosphere on fire. "A Simple Way to Slash Unneccessary Drug Prescriptions" trumpets Scientific American. But is it really all that simple? After all, are the forces that shape inappropriate antibiotic prescription practice all that simple?
A small control group of health care providers from five Los Angelas community clinics agreed to make antibiotic prescriptions available only where medically indicated. They sealed the deal with what behavioral economists might call a commitment device — a signed "Dear Patient" letter outlining the commitment was posted, along with the provider's photograph, in each clinical examination room used by the control group. Lo and behold, the control group brought their antibiotic prescription practices more closely in line with both the commitment and the practice's general standard while the non-control group actually lost ground.
You need to know that inappropriate antibiotic prescription practices used to be thought the low hanging fruit of evidence based medicine, until it turned out to be very difficult to alter clinician antibiotic prescription practices through evidence-based education and outreach. Now inappropriate antibiotic prescription practices are high hanging fruit, I suppose, enticing us with cost and health savings yet tantalizingly out of reach. What makes them hang so high is, in part, that patients have expectations shaped by decades of prescription practice now deemed inappropriate. That is why the letter (posted in both English and Spanish) is a "Dear Patient" letter and written, as I understand it, at a ninth grade level.
What role, then, do the exam room posters play in patient education about appropriate antibiotic prescription practice? Does an advance reading of the poster by patients and their families already begin to re-shape expectations of the clinical encounter even before it begins?
Daniella Meeker, the lead author on the JAMA study, speculates that the commitment device function of the posters made it easier for clinicians to say "no" or served as a reminder on how to respond to patient demands or requests. But, could it also have been that patients dampen their demands when they understand the background story is that antibiotic prescription practices in a given practice are circumscribed and that certain providers endorse the evidence-based approach with enough conviction that they choose to begin the conversation with patients about it during waiting time?
In short, is this a story about just learning to say "no" and mean it ( one take on the clinician's perspective) or is it a story about learning to think before asking (one take on the patient's perspective) or both or neither? As so often occurs when I read articles extolling health care nudges, I can't help but wonder who really got the nudge here?
x-posted at prawfsblawg: http://prawfsblawg.blogs.com/
2 thoughts on “Committing to Reducing Inappropriate Antibiotic Prescriptions”
suggests that the next experiment is 25 clinics, divided into 5 groups.
One, the no change control
two, supersmart multiletters after their names people design a reduce antibiotics program
three, four and five, a used car salesmen, a guy who sells gold on the internet, and a 6th grade teacher design the reduce antibiotics program
Primary Outcome: does group 3,4,or 5 outperform group 2. Statistical limits to be specified in advance; no data dredging
But seriously, the implication is that physician practice is patient demand driven. I had always thought the opposite.
For a moment I thought Ezra was a ‘bot…then I reread his note. 🙂 “who really got the nudge ” I see no reason why the assessment cannot be of a dual purpose proposition.