Los Angeles County (LAC) + USC Medical Center, a large safety-net health system, recently implemented an intervention to decrease inappropriate antibiotic prescribing for upper respiratory infections. This work continues the organization’s dedication to Choosing Wisely after finding previous success in reducing preoperative testing for routine cataract surgery.
“We cannot afford to not address antibiotics use, which is a concern in the safety-net setting,” said Eric Wei, MD, Interim Chief Quality Officer, LAC + USC Medical Center.
After researching behavioral economics and finding inspiration in the 2014 JAMA Internal Medicine research article, “Nudging Guideline-Concordant Antibiotic Prescribing,” Danielle Meeker, PhD, and her colleagues developed a simple behavioral “nudge” in 2012 for clinicians through a poster initiative. A team of clinicians from five Los Angeles community clinics committed to reduce inappropriate antibiotic use by signing poster-sized letters in English and Spanish that hung in exam rooms for patients to read. Another team was the control group and did not sign posters. Results showed that clinicians who signed posters changed their behavior, and inappropriate antibiotic prescribing decreased by about 20 percent.
“This was a clever application of behavioral economics with a public commitment that helps inspire the team,” said John N. Mafi, MD, Assistant Professor of Medicine, University of California, Los Angeles. “This is an example of a low-cost effort to improve evidence-based care, and it was important to see if the concept has traction in different settings.”
The LAC + USC team used the outline of Dr. Meeker’s intervention, but they adapted it to their organization. They created a “group” poster with photos of all providers around the border of the attestation. Clinicians did not want the first time that patients saw them to be through the prescribing posters, so the team also created a “meet your provider” tree display that patients would see when entering the hospital.
The team, which included Dr. Catherine Sarkisian and Carmen Carrillo, also turned signing the posters into a celebration, which leadership attended. To encourage more people to sign the posters, they were left in the breakroom for anyone who could not attend the initial signing.
In addition to the posters, other system support for appropriate antibiotics prescribing included:
- Choosing Wisely materials and patient pamphlets in English and Spanish;
- CDC prescription pads;
- Medical waiver metrics from the Los Angeles County Department of Health Services; and
- Performance feedback about prescribing rates.
As a next step, Dr. Wei said they would love to build another of Dr. Meeker’s intervention—real-time justification of prescribing antibiotics for bronchitis—into the electronic medical record, but early data indicate that the posters are moving prescribing patterns in the right direction at LAC + USC.