A Noticeable Number of Medical Providers Appear to Resist Learning to Use Antibiotics Appropriately over the Long Term

© 2014 Peter Free

 

16 October 2014

 

 

Citation — to the study

 

Jeffrey S. Gerber, Priya A. Prasad, Alexander G. Fiks, A. Russell Localio, Louis M. Bell, Ron Keren, and Theoklis E. Zaoutis, Durability of Benefits of an Outpatient Antimicrobial Stewardship Intervention After Discontinuation of Audit and Feedback, JAMA  doi:10.1001/jama.2014.14042 (online first, 10 October 2014)

 

 

Citation — summary article

 

Kelly Young, David G. Fairchild (editor), and Jaye Elizabeth Hefner (editor), Antibiotic Prescribing Rates Rebound When Feedback to Clinicians Stopped, NEJM Journal Watch (14 October 2014)

 

 

The problem

 

Antibiotic misuse by medical providers (as well as by agriculture) has accelerated the development of bacterial resistance to the drugs.

 

Therefore, parts of the medical establishment have been trying to educate physicians not to prescribe antibiotics where they are not medically appropriate.

 

The study’s authors wanted to find out whether educational attempts actually work.

 

 

Method

 

In October 2008, the research team began using electronic medical records to establish a baseline for broad spectrum antibiotic prescription practices in 18 pediatric primary care settings. These offices spanned reportedly “diverse racial and socioeconomic backgrounds within urban, suburban and rural settings.”

 

The team’s one-hour educational briefing, followed by a year-long prescription writing audit, began in June 2010 in 9 of these practices. The education and feedback intervention ended in June 2011.

 

The other 9 offices served as a non-interventional control group.

 

After the one-year feedback period ended in June 2011, the team monitored prescribing habits through December 2012 in all 18 primary care settings.

 

The idea was to see whether education, combined with active monitoring and feedback, had a long-term effect beyond cessation of the active portion of the intervention.

 

 

Notice that this was statistically non-trivial sample — at least at the patient end of things

 

The team’s report notes that their study included 185,868 individual pediatric patients.

 

These folks made 1,259,938 office visits, distributed among the 18 practices and 180 “clinicians” during the fifty month time period for the entire study.

 

 

Results

 

The findings are a depressing, at least for people who think that human behavior can be modified.

 

Immediately following the intervention effort, which included education and prescription appropriateness feedback, the interventional group had reduced its broad sprectrum antibiotic recommendations from 26.8 to 14.3 percent. And the control group declined its broad spectrum use from 28.4 to 22.6 percent.

 

However, once the feedback period ended for the control group, both groups reverted upward to an higher level than the previous baseline.

 

The interventional group escalated from its 16.7 percent low to a new high of 27.9 percent. And the control group eventually zipped up to 30.2 percent.

 

 

The moral? — You can tell them, but once you stop monitoring their behavior, nothing will have changed

 

I guess this falls into the category that documents the uneducable stubbornness of human beings.

 

The authors conclude that prescription appropriateness feedback has to continue, presumably — I not so facetiously infer — for long enough to pass for nearly forever.