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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.
“We wanted to take the situation and require that the doctor document reasons for prescribing. If they were prescribing inappropriately, this might engender concerns in their mind about their professional reputation, because, upon reflection, they would find themselves unable to give a good justification,” said Dr. Doctor. “We gave them the option to back out if they wanted to, or they could click on the screen and choose an alternative.” Accountable justification also helped lower overprescribing rates from 31% to 7%.
Reg-ent to Help Improve Patient Care, Physician Training
How can peer comparison work in otolaryngology? In 2016, the American Academy of Otolaryngology-Head and Neck Surgery/Foundation introduced its Reg-ent system, a clinical data registry of information used to collect, store, retrieve, analyze, and disseminate information about different otolaryngology diseases, conditions, and outcomes.
Today, a year after it was opened to full clinician participation, the panel consists of 334 practices representing about 1,900 participants, said James C. Denneny III, MD, chair of the Reg-ent Executive Committee and the executive vice president and CEO of AAO-HNS/F. Peer comparison is already a Reg-ent feature, he said
“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,” though it is not searchable for specific physicians beyond one’s own practice, he said. Having comparison information will identify performance improvement measures, which the physician can then follow, document steps taken, and note how patient care is affected by such interventions.
How can Reg-ent help train otolaryngologists to be better at what they do? Analyzing the results of how various treatments are most effective will guide current and future otolaryngology training.
“The volume of registry-based data allows [us to see a] compressed timeline in the evaluation of different treatment modalities,” said Dr. Denneny. “We will know much sooner the results of various treatments and can adjust training for residents as well as those in practice. This also has the potential to broaden trainee experience well beyond their immediate faculty to practitioners in multiple settings across the country.” National and global results can help educate physicians beyond what they see in the clinical settings of their own hospitals. “This should benefit patients in the long run,” he added.
Maintenance of Certification
Part IV of the American Board of Otolaryngology’s (ABOto’s) Maintenance of Certification (MOC), which will address medical practice improvement, is still under development; the ABOto does not currently have a particular timeline for implementation of Part IV. But the idea of using peer comparison will be very effective, said David W. Eisele, MD, FACS, director of the department of otolaryngology-head and neck surgery and professor of oncology at Johns Hopkins Medical Center in Baltimore, and chair of the ABOto MOC committee.
For example, evaluating how head and neck surgeons at different medical institutions follow accepted guidelines for oral cavity cancer management and then comparing oneself to those peers can inform a practitioner of areas for practice improvement, said Dr. Eisele. “This type of assessment is basically the mechanism by which you get feedback,” he added. “You compare yourself to others and then you actively make changes to practice to better conform to guidelines and best practices.”
Dr. Eisele stressed that any kind of peer comparison methods in otolaryngology that are incorporated into the MOC would be beneficial to all otolaryngologists. “This process will be designed so it is not an onerous time commitment, and it will be fairly painless once the process is initiated,” he said. “We don’t want this to be a burden for our diplomates; we want it to enhance their practice in medicine, with better outcomes and more healthy patients. All physicians want to improve patient care, and we expect that this will help.”
That’s a goal echoed by Dr. Doctor. “We are trying to move toward an understanding of what practices are harmful or provide low-value care,” he said. “If they are harmful or not valuable for patients, we shouldn’t do them.”
Cheryl Alkon is a freelance medical writer based in Massachusetts.
Poster-Sized Commitment
A 2014 study published in JAMA Internal Medicine and coauthored by Dr. Doctor used the principle of publication commitment to change prescriber behavior (JAMA Intern Med. 2014 Mar;174:425–431). In a signed letter to patients, clinicians discussed the importance of lowering the rate of inappropriate antibiotic prescribing and stated their dedication to prescribing antibiotics only when they are absolutely necessary.
These letters were enlarged to poster size and placed in exam rooms. This tactic, or “nudge,” as study authors called it, reduced rates by nearly 20%.
Accountable Justification
Accountable justification is an EHR-based intervention used in Dr. Doctor’s JAMA study. An EHR prompt asked each clinician seeking to prescribe an antibiotic to explicitly justify, in a free-text response, his or her treatment decision. The prompt also informed clinicians that this written justification would be visible in the patient’s medical record as an “antibiotic justification note” and that if no justification was entered, the phrase “no justification given” would appear.
Encounters could not be closed without the clinician’s acknowledgment of the prompt, but clinicians could cancel the antibiotic order to avoid creating a justification note, if they chose. The accountable justification alert was triggered for both antibiotic-inappropriate diagnoses and potentially antibiotic-appropriate acute respiratory tract infection diagnoses (e.g., acute pharyngitis).
The accountable justification intervention was based on prior findings that accountability improves decision-making accuracy and that public justification engenders reputational concerns. To preserve their reputations, clinicians should be more likely to act in line with injunctive norms—that is, what one “ought to do” as recommended by clinical guidelines. The authors found a drop in antibiotic prescribing from 23.2% to 5.2% when this method was in use.