Can We “Nudge” Our Way Out of Antibiotic Resistance?
New evidence drawing on principles of behavioral economics and “nudge” theory may provide a way forward.
Without urgent action, “the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill,” according to Dr. Keiji Fukuda, WHO’s Assistant Director-General for Health Security.
While the advent of antibiotics has been a game changer in modern medicine, enabling us to live longer and healthier lives, microbes such as bacteria are constantly evolving and developing new ways to survive. Selective pressure and mutations naturally contribute to antibiotic resistance, but inappropriate use of antibiotics speeds up the process.
Fortunately, new evidence drawing on principles of behavioral economics and “nudge” theory may provide a way forward.
Can "Nudge Theory" be the Tonic the Doctors Need?
Researchers at University of Southern California (USC) studied low-cost approaches to “nudge” physicians into reducing unnecessary prescriptions for antibiotics.
The study followed 248 primary care physicians in Boston and Los Angeles and studied the impact of three evidence-based nudging interventions on prescription practices:
- Peer comparison: Physicians were sent a monthly email stating either: “you are a top performer” or “you are not a top performer” based on their rate of inappropriate antibiotic prescriptions.
- Accountable justification: A prompt requested the physician to justify the prescription before it was entered in the patient’s electronic record.
- Suggested alternative: A pop-up box suggested alternative treatments whenever a physician ordered an antibiotic for infections that were treatable without antibiotics.
The peer comparison and accountable justification interventions “collectively prevented on average of one inappropriate prescription for every eight patients seen.”
However, 12 months after the interventions had ended, antibiotic prescription rates increased once again from 4.8 to 6.3 percent for the peer comparison intervention and 6.1 to 10.2 percent for the accountable justification intervention.
A similar study conducted in Australia with general practitioners yielded promising results. Australia’s Chief Medical Officer sent personalized letters to general practitioners (GPs) whose antibiotic prescription rates were in the top 30% for their region. Letters included peer comparison feedback with either educational information, information and materials to support delayed prescribing, or an attention-grabbing graph.
There was a dramatic reduction in prescription rates between 9.3 percent and 12.3 percent six months after the letters were sent. Simply providing educational information alone was the least effective approach, but peer comparison feedback (i.e. “you prescribe more antibiotics than 92% of prescribers in your region”) with a graph was highly effective.
Nudge theory has been extensively studied by behavioral economists as a method of positive reinforcement to guide decision making processes, but it also has tremendous implications in public health practice.
While the evidence is preliminary, similar studies can be carried out in lower and middle income countries, where antibiotic use is rampant and on the rise.
Would It Work in an Indian Scenario?
With a population of approximately 1.3 billion, the country faces dire health challenges with a double burden of communicable and non-communicable diseases.
Antibiotic use more than doubled, from 3.2 billion defined daily doses (DDD) to 6.5 billion, between 2000 and 2015 in India.
The public sector in India has strict guidelines on the use of antibiotics, but well over 70 percent of residents utilize the private sector for care and treatment instead. To further complicate matters, the private sector is comprised of formal providers as well as informal practitioners, and antibiotics are commonly used as a prophylaxis to compensate for poor sanitation and inadequate infection control practices.
In such a context, reducing inappropriate dispensing practices is not only a smart policy decision, but it is also of paramount importance to arrest the growth of antibiotic resistance.
That being said, successful implementation of nudge behaviors requires systematic data on prescription patterns, which varies state by state and is often not available in the Indian context. Data regarding the prescription practices of informal providers who are often set up in remote corners across rural areas is even more limited.
India recently introduced its national action plan to combat antimicrobial resistance in keeping with recommendations by the World Health Organization, and strengthening knowledge and evidence through surveillance is listed as a key strategic goal. Perhaps alongside strengthening laboratories and surveillance mechanisms, studies across tertiary medical colleges could examine prescription patterns and document drivers for particular prescription choices.
Based on this data, a pilot program can be launched in a few selected hospitals in urban areas to test how physicians respond to receiving information about their own prescription behaviors in relation to national and international norms. The public sector would be the best place to start, because it functions as an organized and decentralized bureaucracy despite financial shortfalls.
Once preliminary results are in place in the public sector, similar studies can be conducted in the formal and informal private sector, with qualified and unqualified medical professionals alike. Unqualified practitioners practice without legal authority, but often form the backbone of care provision in remote and rural areas which are removed from the existing health system. Reigning in the prescription practices of informal providers may be a herculean task given the prevailing market dynamics and the reliance on antibiotics as a way to acquiesce to patient demands of “quick cures.”
Even if a pilot program were to successfully demonstrate sustained reductions in inappropriate prescriptions in the public sector alone, the impact would be significant. Just last year, a study conducted at a tertiary hospital in India found that 58% of sampled patients were prescribed antimicrobials and more than 40% of these prescriptions were inappropriate.
Behavior change is no easy task in a country plagued by inadequate health expenditure, poor access to diagnostics, limited health infrastructure, and an unmanageable case load. However, if are to heed the WHO’s warning and prevent Dr. Fukuda’s apocalyptic vision from coming into fruition, policy makers must borrow from multiple disciplines as we attempt to nudge our way out of inappropriate dispensing behavior and into judicious use of antibiotics.
(Mohit Nair is a researcher and freelance journalist dedicated to addressing critical public health challenges in India. Through research and advocacy, he hopes to raise awareness around issues pertaining to global health equity. Mohit holds a MPH from Harvard’s Chan School of Public Health and a degree in Biological Sciences from Cornell University.)
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