Reference: JAMA Intern Med. 2023 Feb 6 early online
Practice Point: Peer pressure isn’t enough to reduce antibiotic overprescribing.
EBM Pearl: Claims data can seem like a free gift to researchers, but for some questions, they get what they pay for.
Inappropriate prescribing of antibiotics is a serious and somewhat intractable problem. There are concerns about unnecessary adverse effects on patients, risks for new infections such as C. diff or candida, as well as increasing antimicrobial resistance among bacteria. Yet despite ongoing public awareness campaigns and attempts at educating clinicians, antibiotics are commonly prescribed where there is no medical indication, particularly for acute respiratory illnesses. One proposed method is to give clinicians data comparing their prescription profiles to those of their peers in an attempt to influence high prescribers to be more selective in their use of antibiotics. There have been some examples of this making some impact, but the generalizability of those findings remains a question.
In a recent large trial from Switzerland, 3,426 PCPs from 3 health insurer databases covering 50% of residents with medium-high antibiotic prescribing rates were randomized to quarterly audit with peer comparison or no intervention. They were then followed for 2 years with the primary outcome being prescribing of antibiotics in the 2nd year of the program. In the intervention group, 8.2 antibiotics were prescribed for every 100 office visits, compared to 8.4 prescriptions/100 visits in the control group, a nonsignificant difference. Moreover, antibiotic prescribing overall actually rose by 4.2% in both groups.
This trial had two key limitations. Swiss claims data does not match antibiotic prescriptions with a diagnosis, so it is hard to know how much of the prescribing was necessary. We also don’t know if the prescribers even read the audit reports. Nonetheless, these data suggest clinicians are not influenced by peer opinions as much as the proponents of this approach might hope. Perhaps it’s more education on alternatives to immediate antibiotic prescription options that we need, such as use of delayed prescriptions which have been shown to dramatically reduce the inappropriate use of antibiotics. It could be, however, that in order to achieve antimicrobial stewardship goals we need healthcare systems which allow providers more than 10-20 minutes per patient so that there is time for meaningful patient education about proper antibiotic use, as well as other important messages about how to stay healthy.
For more information, see the topic Antimicrobial Stewardship in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School. Edited by Katharine DeGeorge, MD, MS, Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Dan Randall, MD, Deputy Editor at DynaMed; Nicole Jensen, MD, Family Physician at WholeHealth Medical; Vincent Lemaitre, PhD, Senior Medical Writer at DynaMed; and Sarah Hill, MSc, Associate Editor at DynaMed.