Behavioral approach to appropriate antimicrobial prescribing in hospitals: The DUMAS study


Clinical question: How effective is an antimicrobial stewardship approach grounded in behavioral theory and focused on preserving prescriber autonomy and participation in improving appropriateness of antimicrobial prescribing in hospitals?

Background: Antimicrobial stewardship programs aim to achieve the goal of improving antimicrobial prescribing. This leads to significant benefits, including decreased antimicrobial resistance, improved clinical outcomes (lower morbidity and mortality), and lower health care costs. Stewardship programs do not often focus on the human behavior element of the prescribing physicians. Changing antimicrobial prescribing is a complex behavioral process, and there is a known persistent resistance between prescribers and the stewardship team. In a simple sense, this resistance is generated by tension created when prescribers do not have autonomy.

Previous studies that used interventions based on behavioral theory found promising results, but none of them were in a hospital setting. Rather, most of these studies had a narrow focus of respiratory tract infections in outpatient clinics.

Study design: Prospective, stepped-wedge, participatory intervention study.

Setting: Seven clinical departments (two medical, three surgical, and two pediatric) in a tertiary care medical center and a general teaching hospital, both in Amsterdam. The first hospital was a 700-bed tertiary care center with salaried specialists, while the second hospital was a 550-bed general medical center with self-employed specialists.

Synopsis: During a baseline period of 16 months and an intervention period of 12 months, physicians who prescribed systemic antimicrobial drugs for any indication were included in the study. In all, 1,121 patient cases with 700 prescriptions were studied during the baseline period and 882 patient cases with 531 prescriptions were studied during the intervention period. The intervention was as follows: Prescribers were offered a free choice of how to improve their antimicrobial prescribing. They were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing. The study was inspired by the participatory action research paradigm, which focuses on collaboration and empowerment of the stakeholders in the change process. In this study, prescribers were given reports of root cause analysis of their prior prescribing patterns. Then, they were invited to choose and codevelop one or more interventions that were tailored and individualized to improve their own prescribing. This approach draws on the following three behavioral principles: 1) respect for the prescriber’s autonomy to avoid feelings of resistance; 2) the inclination that people have to value a product higher and feel more ownership of it if they made it themselves (the IKEA effect); 3) the tendency of people to follow up on an active and public commitment.

The primary outcome was antimicrobial appropriateness, measured with a validated appropriateness assessment instrument. One of three infectious disease specialists assessed the adult prescriptions, and one of three infectious disease/immunology pediatricians assessed the pediatric prescriptions for appropriateness. Appropriateness criteria were as follows: indication, choice of antimicrobial, dosage, route, and duration. A secondary outcome was antimicrobial consumption, reported as days of therapy per 100 admissions per month. Other outcomes were changes in specific appropriateness categories, intravenous antimicrobial consumption, consumption of specific antimicrobial subgroups, and length of hospital stay.

The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. Antimicrobial consumption remained the same during both study periods. Length of hospital stay did not change relative to the start of the intervention approach.

This is the first study of its kind, as a hospital antimicrobial stewardship program study grounded in behavioral science, with the key element being the free choice allowed to the prescribers, who made their own autonomous decisions about how to improve their prescribing. The authors hypothesize that the prescribers felt relatively nonthreatened by their approach since the prescribers maintained their free will to change their own behavior if so desired. The prescribers were given a free intervention choice. For example, they could have just chosen “education” as an easy out; however, the root cause analysis seemed to be an impetus for the prescribers to choose interventions that would be more effective. A prior study in a nursing home setting was unsuccessful; aside from other differences, that study used a predetermined set of interventions, thus lacking the autonomy and IKEA effect seen in this study.

Bottom line: Use of a behavioral approach that preserves prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The intervention is effective, inexpensive, and transferable to various health care settings.

Citation: Sikkens JJ, van Agtmael MA, Peters EJG, et al. Behavioral approach to appropriate antimicrobial prescribing in hospitals: The dutch unique method for antimicrobial stewardship (DUMAS) participatoryintervention study. JAMA Intern Med. Published online May 1, 2017. doi: 10.1001/jamainternmed.2017.0946.

Dr. Ramee is a hospitalist at Ochsner Health System, New Orleans.

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