Behavioral interventions can reduce inappropriate antibiotic prescribing practices among primary care clinicians, according to a study published in JAMA.

A majority of antibiotic prescriptions written in the United States are for acute respiratory tract infections, including upper respiratory tract infections, acute bronchitis, and influenza. However, antibiotics are not indicated for many of these conditions.

To reduce inappropriate antibiotic prescribing rates, Daniella Meeker, PhD, of the Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, and colleagues tested the efficacy of three different behavioral interventions.

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The study included 248 clinicians from 47 primary care practices in Boston and Los Angeles. During a period of 18 months, each participant was randomized to receive 0, 1, 2, or 3 types of behavioral interventions. All participants were educated about antibiotic prescribing guidelines upon enrolling in the study.

The three interventions used were:

  • Suggested alternatives: Clinicians were sent electronic order sets that suggested non-antibiotic treatments.
  • Accountable justification: Clinicians entered typed justifications for prescribing antibiotics to a patient into their electronic health records.
  • Peer comparison: Clinicians were sent emails that compared their antibiotic prescribing rates with rates of clinicians with the lowest inappropriate prescribing rates.

Before the intervention period, the researchers measured inappropriate antibiotic prescription rates for an 18-month baseline period.

The clinicians had 14,753 patients present with antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 during the intervention period.

After the baseline period, mean antibiotic prescribing rates for acute respiratory tract infections in the control group were 24.1%, decreasing to 13.1% after the intervention period. In the suggested alternatives group, rates decreased from 22.1% to 6.1%; in the accountable justification group, rates decreased from 23.2% to 5.2%; and in the peer comparison group, rates decreased from 19.9% to 3.7%.

No statistically significant interactions were found between different types of interventions.

According to an accompanying editorial written by Jeffrey S. Gerber, MD, PhD, of the Children’s Hospital of Philadelphia, “This report highlights the promise of various types of immediate feedback to improve antibiotic prescribing and justifies further investigation to devise the most effective, generalizable, and sustainable interventions.

“This might require tailoring the intervention to specific practice, practitioner, or patient characteristics. Future work should also expand to focus on the most common infections for which antibiotics are sometimes (but often not) indicated, such as acute pharyngitis and sinusitis (although these conditions triggered the nudge in this intervention, prescribing rates for pharyngitis and sinusitis were not measured), and to optimize guideline-concordant antibiotic choice (narrower) and duration of therapy (shorter) for common bacterial infections.”


  1. Meeker D, Linder JA, Fox CR, et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275.
  2. Gerber JS. Improving outpatient antibiotic prescribing. Another nudge in the right direction. JAMA. 2016;315(6):558-559. doi: 10.1001/jama.2016.0430