Use of Behavioral Economics to Improve Treatment of Acute Respiratory Infections (Main Study)
- Conditions
- Acute Respiratory Infections (ARIs)
- Registration Number
- NCT01454947
- Lead Sponsor
- University of Southern California
- Brief Summary
Bacteria resistant to antibiotic therapy are a major public health problem. The evolution of multi-drug resistant pathogens may be encouraged by provider prescribing behavior. Inappropriate use of antibiotics for nonbacterial infections and overuse of broad spectrum antibiotics can lead to the development of resistant strains. Though providers are adequately trained to know when antibiotics are and are not comparatively effective, this has not been sufficient to affect critical provider practices.
The intent of this study is to apply behavioral economic theory to reduce the rate of antibiotic prescriptions for acute respiratory diagnoses for which guidelines do not call for antibiotics. Specifically targeted are infections that are likely to be viral.
The objective of this study is to improve provider decisions around treatment of acute respiratory infections.
The participants are practicing attending physicians or advanced practice nurses (i.e. providers) at participating clinics who see acute respiratory infection patients. A maximum of 550 participants will be recruited for this study.
Providers consenting to participate will fill out a baseline questionnaire online. Subsequent to baseline data collection and enrollment, participating clinic sites will be randomized to the study arms, as described below.
There will be a control arm, with clinic sites randomized in a multifactorial design to up to three interventions that leverage the electronic medical record: Order Sets that are triggered by electronic health record (EHR) workflow containing exclusively guideline concordant choices (SA, for Suggested Alternatives); Accountable Justifications triggered by discordant prescriptions that populate the note with provider's rationale for guideline exceptions (AJ); and performance feedback that benchmarks providers' own performance to that of their peers (PC, for Peer Comparisons).
The outcomes of interest are antibiotic prescribing patterns, including prescribing rates and changes in prescribing rates over time.
The intervention period will be over one year, with a one-year follow up period to measure persistence of the effect after EHR features are returned to the original state and providers no longer receive email alerts.
- Detailed Description
Each consented provider will be randomized to 1 of 8 cells in a factorial design with equal probability. If results of retrospective data analysis imply that design will be improved by stratification, randomization will be stratified by factors that could influence outcomes.
Data will be collected from the clinics' Enterprise Data Warehouses which store copies of data recorded in the electronic health record. Data elements from qualifying office visits will be collected from coded portions of the electronic health record.
An encounter is eligible for intervention if the patient's diagnosis is in the selected group of acute respiratory infections. The intervention EHR functions will be triggered when clinicians initiate an antibiotic prescription or enter a diagnosis for an acute respiratory infection that has a defined Order Set. If an antibiotic from a list of frequently misprescribed antibiotics is ordered and a diagnosis has not yet been entered, providers will be prompted to enter a diagnosis. If the diagnosis entered is acute nasopharyngitis; acute laryngopharyngitis/acute upper respiratory infection; acute bronchitis; bronchitis not specified as acute or chronic; or flu; the interventions will be triggered. The diagnosis-appropriate order set will pop-up for providers in the SA arm, while clinicians randomized to the AJ arm will receive an alert and be required to enter a brief statement justifying their antibiotic prescription if antibiotics are not indicated for the diagnosis entered. This note will then be added to the patient's medical record.
Clinicians randomized to the Peer Comparison condition will receive email updates about their antibiotic prescribing practices relative to other clinicians in their practice.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 248
- A practicing attending physician or advanced practice nurse ("provider") at a participating clinic in 2011-2013 who sees acute respiratory infection patients.
- None.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- FACTORIAL
- Primary Outcome Measures
Name Time Method Inappropriate Antibiotic Prescribing Rate for Qualifying Acute Respiratory Infection Diagnoses 18 months Assess inappropriate antibiotic prescribing rates (relative to all practices that did not receive the intervention) for antibiotic-inappropriate acute respiratory tract infection visits and no concomitant reason for antibiotic prescribing. based on the following non-antibiotic-appropriate International Statistical Classification of Diseases, version 9 (ICD-9) diagnoses:
460 Acute nasopharyngitis (common cold)
465 Acute laryngopharyngitis/acute upper respiratory infection
466 Acute bronchitis
490 Bronchitis not specified as acute or chronic
487 Flu
- Secondary Outcome Measures
Name Time Method Encounters Closely Following the Index Encounter for Serious Diagnoses 18 months Within intervention-qualifying acute respiratory infections (ARI) encounters where no antibiotic was prescribed, we will monitor return visit rates for the specified diagnoses and other acute respiratory infection diagnoses (ICD-9), including whooping cough (033.9), rheumatic fever (390-392) and pneumonia (481-487).
Trial Locations
- Locations (55)
Altamed Anaheim Lincoln
🇺🇸Anaheim, California, United States
Altamed Bell Clinic
🇺🇸Bell, California, United States
Altamed DVL El Monte
🇺🇸El Monte, California, United States
Altamed Anaheim West
🇺🇸Anaheim, California, United States
Altamed Mobile Unit Primary Care
🇺🇸Commerce, California, United States
Altamed El Monte Clinic
🇺🇸El Monte, California, United States
Altamed PACE Rugby
🇺🇸Huntington Park, California, United States
Altamed Huntington Beach Clinic
🇺🇸Huntington Beach, California, United States
Altamed Garden Grove Harbor
🇺🇸Garden Grove, California, United States
The Children's Clinic Family Health Center at Hamilton Middle School
🇺🇸Long Beach, California, United States
The S. Mark Taper Foundation Children's Clinic Family Health Center
🇺🇸Long Beach, California, United States
The Children's Clinic Family Health Center at Cesar Chavez Elementary School
🇺🇸Long Beach, California, United States
The Children's Clinic at the Long Beach Multi-Service Center for the Homeless
🇺🇸Long Beach, California, United States
The Vasek Polak Children's Clinic Family Health Center
🇺🇸Long Beach, California, United States
Altamed William Mead Homes
🇺🇸Los Angeles, California, United States
Altamed PACE Grand Plaza
🇺🇸Los Angeles, California, United States
Altamed Commerce Clinic
🇺🇸Los Angeles, California, United States
Altamed PACE Pomona
🇺🇸Los Angeles, California, United States
Altamed DVL Commerce
🇺🇸Los Angeles, California, United States
Altamed Boyle Heights Clinic
🇺🇸Los Angeles, California, United States
Altamed Estrada Courts
🇺🇸Los Angeles, California, United States
Altamed Zonal Clinic
🇺🇸Los Angeles, California, United States
Altamed Ramona Gardens
🇺🇸Los Angeles, California, United States
AltaMed 1st St Boyle Heights Clinic
🇺🇸Los Angeles, California, United States
Altamed El Modena Clinic
🇺🇸Orange, California, United States
Altamed Pico Clinic
🇺🇸Pico Rivera, California, United States
Altamed DVL Pico
🇺🇸Pico Rivera, California, United States
Altamed Santa Ana Main
🇺🇸Santa Ana, California, United States
Altamed Clinic For Women
🇺🇸Santa Ana, California, United States
Altamed Santa Ana Broadway
🇺🇸Santa Ana, California, United States
Altamed Santa Ana Central
🇺🇸Santa Ana, California, United States
Brigham and Women's Primary Care Associates at Foxborough
🇺🇸Boston, Massachusetts, United States
Mass General Medial Group
🇺🇸Boston, Massachusetts, United States
MGH Downtown
🇺🇸Boston, Massachusetts, United States
MGH Beacon Hill
🇺🇸Boston, Massachusetts, United States
MGH Senior Health
🇺🇸Boston, Massachusetts, United States
Women's Health Associates
🇺🇸Boston, Massachusetts, United States
Brigham Circle Medical Associates
🇺🇸Boston, Massachusetts, United States
Brigham Internal Medicine Associates
🇺🇸Boston, Massachusetts, United States
Spanish Clinic
🇺🇸Boston, Massachusetts, United States
Brigham and Women's Primary Care Associates of Brookline
🇺🇸Brookline, Massachusetts, United States
MGH Back Bay
🇺🇸Boston, Massachusetts, United States
MGH Charlestown HealthCare Center
🇺🇸Charlestown, Massachusetts, United States
MGH Chelsea HealthCare Center
🇺🇸Chelsea, Massachusetts, United States
Brigham and Women's Physician Group
🇺🇸Chestnut Hill, Massachusetts, United States
Everett Family Practice
🇺🇸Everett, Massachusetts, United States
Gretchen and Edward Fish Center for Women's Health
🇺🇸Chestnut Hill, Massachusetts, United States
Brigham Primary Physicians at Faulkner
🇺🇸Jamaica Plain, Massachusetts, United States
Brookside Community Health Center
🇺🇸Jamaica Plain, Massachusetts, United States
Faulkner Community Physicians
🇺🇸Jamaica Plain, Massachusetts, United States
Brigham and Women's Primary Care Associates of Newton Corner
🇺🇸Newton, Massachusetts, United States
Mass General Revere HealthCare Center
🇺🇸Revere, Massachusetts, United States
Mass General West Medical Group
🇺🇸Waltham, Massachusetts, United States
Altamed Montebello Clinic
🇺🇸Montebello, California, United States
Southern Jamaica Plain Health Center
🇺🇸Jamaica Plain, Massachusetts, United States