The results of a recent study published in JAMA indicate that behavioral interventions meant to improve clinician antibiotic prescribing habits require ongoing reinforcement.

Jeffrey A. Linder, MD, MPH, of the Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues conducted a randomized trial of 3 behavioral interventions, including 47 primary care practices and 248 clinicians, with the goal of reducing inappropriate antibiotic prescribing.

All clinicians received education on antibiotic prescribing guidelines. Two of the behavioral interventions were electronic health record (EHR)-based.

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The “suggested alternatives” intervention provided non-antibiotic treatment alternatives when clinicians attempted to prescribe antibiotics for acute respiratory infections (ARIs), while the second intervention, “accountable justification,” prompted clinicians to enter free-text written justification for prescribing antibiotics for ARIs. The “peer comparison” intervention sent monthly emails to clinicians comparing their inappropriate antibiotic prescribing rates for ARIs to clinicians with the lowest rates.

Baseline antibiotic prescribing was measured beginning 18 months before the start of the intervention and continued until 18 months after the intervention ended. The accountable justification and peer comparison interventions were significantly effective compared with control practices. However, 12 months after the end of the interventions, inappropriate antibiotic prescribing for ARIs in the intervention groups increased relative to control practices. Inappropriate prescribing increased from 7.4% to 8.8% for the suggested alternatives group, and from 6.1% to 10.2% for the accountable justification group. For the peer comparison group, prescribing increased from 4.8% to 6.3%.

Inappropriate prescribing rates continued to decrease in the control practices from 14.2% to 11.8%. Durable improvements were achieved only in the peer comparison group, which remained significantly lower than the control group, but the investigators noted that these might diminish further over time and suggest applying interventions on a long-term basis.


Linder JA, Meeker D, Fox CR, et al. Effects of behavioral interventions on inappropriate antibiotic prescribing in primary care 12 months after stopping interventions. JAMA. 2017;318(14):1391-1392.