Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals

Abstract

IMPORTANCE Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.OBJECTIVE To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals. DESIGN, SETTING, AND PARTICIPANTSThe Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study. INTERVENTIONSWe offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.MAIN OUTCOMES AND MEASURES Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.RESULTS A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.CONCLUSIONS AND RELEVANCE Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

Comparative point prevalence survey of antimicrobial consumption between a hospital in Northern Ireland and a hospital in Jordan

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How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project

“…Although the evidence in this field is still limited, PAR is promising to optimise antibiotic prescribing behaviour, and solutions are needed now more than ever. 17–19 The literature on different types of interventions to improve antibiotic prescribing is growing as is the interest in why interventions work or not. 20–23 When working on interventions to improve antibiotic prescribing, studying and reflecting on the specifics of the context and setting are important to come up with tailored bottom-up supported solutions.…”

Physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukemia: results of a national survey

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