Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

Abstract

ObjectivesAntibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall.MethodsMedline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group’s tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness.ResultsNineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers.ConclusionsNudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study

“…A similar study in the United Kingdom found an approximate 5% reduction in antimicrobial prescribing when letters were sent to primary care physicians in the top 20% of antimicrobial prescribers. 54 Although the literature is mixed, 55 peer comparison remains a relatively low-intensity intervention to reduce antimicrobial exposure at scale. Developing peer-comparison interventions that target prescribers in the top 3 quartiles, rather than only the highest quartile or outliers, may help further reduce antimicrobial prescribing in the hospital setting.…”

Generalizability and Effectiveness of Choice Architecture Interventions

“…These published systematic reviews cover a wide range of behaviors. These include healthy food choices 25,[29][30][31][32][33][34][35][36][37][38][39] , dietary behaviors [40][41][42][43][44] , other health related behaviors 36,[45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60] , environmental behaviors [61][62][63][64][65][66][67] , disclosure of personal information 68 , tax compliance 69 , learning behavior 70 and children's sleep 71 . Additionally, some of the reviews address various types of interventions such as digital nudges 72 or default options 73 .…”

“Nudging” clinicians to communicate more effectively with patients in hospital

“…Nudge interventions are attempts to shape behaviors through subconscious attitudes or routines that influence decision making 7. Nudge interventions have been found to be useful in a variety of decision processes, including antibiotic prescribing and hand hygiene 89. Important methodological considerations underlie the application of nudge strategies to doctors’ sitting behavior, including questions about whether the study design and nudge can account for other salient dynamics that shape patients’ perceptions of communication.…”