Physician-To-Physician Comparison May Improve Outcomes

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Every physician is dedicated to doing no harm. But, when it comes to prescribing antibiotics, it turns out some physicians are, in fact, causing harm. The rise of antibiotic resistance has occurred not because physicians don’t know better but rather as a result of influences that are often shaped by social forces.

When a group of primary care physicians saw how they compared with their peers, and found themselves ranked lower the more antibiotic prescriptions they wrote, their standings became recognized as an effective way to get physicians to stop reaching for their prescription pads as frequently, according to research published in 2016 (JAMA. 2016;315:562-570). These investigators analyzed antibiotic prescription rates among 248 clinicians in Boston and Los Angeles over an 18-month period. Researchers found that peer comparison, along with another technique called “accountable justification,” which required peer accountability through chart note justification for antibiotic prescriptions, effectively changed physician behavior and helped lower inappropriate antibiotic prescribing for acute respiratory tract infections..

Why were these methods so successful, and how can they work in otolaryngology?

How Patterns Shift

The study showed how to effectively change behavior, said Jason N. Doctor, PhD, the Norman Topping Chair in Medicine and Public Policy at the University of Southern California’s Sol Price School of Public Policy, director of health informatics at the Leonard D. Schaeffer Center for Health Policy and Economics, in Los Angeles, and the study’s corresponding author. “What we’ve been doing represents one strategy to address low-value care, and to instead substitute things that carry less harm,” he added.

His research, performed with colleagues in Boston and Los Angeles, focused on determining what strategies are successful in changing behavior, because most physicians understand antibiotic overprescribing and don’t require additional education.

Additionally, given the fact that medications were often prescribed because patients wanted something to help them feel better, had traveled while sick to see the doctor, and would likely see their illnesses resolve five to seven days later regardless of antibiotic use, physicians weren’t typically seeing the negative outcome of overuse. “They were thinking about the clinical case and weren’t thinking so much about antibiotic resistance or preserving the effectiveness of antibiotics,” said Dr. Doctor. “This is more of a social and a public health problem than a clinical one.”

Peer comparison, though, helped address these problems. “We’d rank top performers and send emails to the physicians in a practice that would only disclose their own performance,” he said. Physicians were ranked compared with others in the study based in the same region. “We’d tell them what the top performers’ rate of prescribing was, what theirs was, and then provide material on recommended guidelines.” The healthy competition inspired physicians to be more thoughtful: Over the 18-month study period, inappropriate prescription rates dropped from 31% to 5%.

Reg-ent will allow participating physicians to compare their performances on self-selected quality measures to other physicians within their group as well as nationally. —James C. Denneny III, MD

Other interventions also helped lower rates. A method called accountable justification connected to the physicians’ electronic health records. When physicians wanted to prescribe an antibiotic for an acute respiratory infection, a prompt would pop up in the computer system. It would remind physicians of the guidelines, and while they were still able to prescribe, the prompt required one or two sentences justifying the prescription and then became a part of the patient’s record.