Fighting the Looming Antibiotic Crisis

Nathan: How would you define the focus of your research to a general audience?

Dr. Cummings: Antibiotic resistance is when an organism that would ordinarily be sensitive to an antibiotic becomes resistant to it. In other words, it is the ability of bacteria to change in a way that reduces the effectiveness of drugs. Antibiotic resistance is an urgent public health threat globally, affecting all countries, regardless of socioeconomic status. One of the primary drivers contributing to the emergence and persistence of this threat is antibiotic misuse. In the United States, a majority of antibiotics are prescribed unnecessarily during flu season for likely viral infections. Antibiotics do not work against viruses, they only work against bacteria. So, our research aims to identify and mitigate the factors that contribute to this issue, so that we can ultimately prevent and reduce the threat of antibiotic resistance.

Nathan: How do those themes narrow into a specific project?

Dr. Cummings: Inappropriate antibiotic prescribing may be influenced by a number of factors, like physician characteristics (e.g., knowledge, memory, training, number of years in practice), but it can also be influenced by external forces, such as a patient putting pressure on a physician to prescribe them an antibiotic when it is not needed. Our research question for this first study was, “are behavioral science interventions effective in reducing unnecessary antibiotic prescribing among physicians in our community hospital setting?”

Nathan: How was your project designed?

Dr. Cummings: One of the behavioral science interventions we implemented was called “peer comparison.” We ranked physicians against their peers (other physicians in the group) by giving them their prescribing data. We also emailed a blinded ranking list to all the physicians in the group, so they could see where they ranked against their peers. We did this by assigning them a random number, so they were not identified in the public email, but could see how well they were doing compared to their peers. We hypothesized that the peer comparison strategy would work best or result in the greatest decrease in unnecessary antibiotic prescribing since providers tend to be inherently competitive in nature. We also believed that by giving them their data, it empowered them to do better (i.e., social desirability) while creating a competition-like environment among their peers. The other interventions we implemented were patient and staff education, and public commitment. These were supportive, but not as effective as the peer comparison strategy.

Nathan: What rough process did you follow?

Dr. Cummings: We were lucky we didn’t need to reinvent the wheel – we adapted a process from existing studies that have been published on this topic. Specifically, we used work published by Dr. Larissa May at the University of California Davis who has done research in this area, as well as Dr. Daniella Meeker and Dr. Jason Doctor from the University of Southern California. Their work helped us to adapt and develop the interventions to our community hospital setting and population.

Nathan: What did you end up finding out?

Dr. Cummings: Our results showed there were significantly fewer inappropriate antibiotic prescriptions written during the intervention period than the pre-intervention period, resulting in a significant decrease in the rate of inappropriate antibiotic prescribing among physicians over a 6-month period. The strategies included in this intervention suggest that utilizing a behavioral science approach for antimicrobial stewardship may greatly reduce inappropriate antibiotic prescribing.

Nathan: How do you think this is relevant to an applied setting (i.e., in business or public policy)?

Dr. Cummings: Like many behaviors, antimicrobial prescribing is a complex behavior that is influenced by a combination of factors. Aside from individual provider factors, there are a number of outside influences that differ by context and setting. What the published evidence currently tells us is that some of these factors lead to better sustainability than others, such as peer comparison. Applying this to other sectors, such as fast food and beverage industries, we know that external factors (e.g., price, convenience, and advertising) have a heavy impact on what we choose to eat. Sometimes these external factors have a greater impact on our decision-making than individual-level factors. The most important takeaway here is to identify and learn what factors have the most influence and to leverage those factors’ effects on people’s behavior. In our case, we leveraged those factors to improve quality and patient safety, as well as contribute to a global public health goal of reducing antibiotic resistance. 

Nathan: Do you see future research stemming from your study? In what direction?

Dr. Cummings: Yes, we are about to launch the next phase of this study, which will examine physician-level characteristics that may influence the likelihood of prescribing antibiotics (e.g., age, training, number of years in practice) and we will look at how these factors contribute to the sustainability of the intervention over time. This work will be important to inform the sustainability of these interventions and will provide much-needed data for other community hospitals looking to implement similar interventions.