Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics.

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From: Mayo Clinic Proceedings(Vol. 96, Issue 3)
Publisher: Elsevier, Inc.
Document Type: Report
Length: 2,853 words
Lexile Measure: 1800L

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The challenges posed by rising rates of antibiotic resistance cannot be overstated. Antibiotic resistance results in worse outcomes and higher costs. In the outpatient setting, internists too frequently encounter patients with infections that have no effective oral options for treatment. (1) The Centers for Disease Control and Prevention (CDC) estimates that more than 2.8 million antibiotic-resistant infections occur in the United States each year and result in approximately 35,000 deaths. (1) Health care costs attributed to antibiotic-resistant infections surpass 2 billion dollars annually.

Outpatient clinicians contribute to the increase in antibiotic resistance through antibiotic overuse: the prescribing of antibiotics when not medically necessary, for durations longer than necessary, and the use of broader-spectrum antibiotics when narrower-spectrum agents would be equally, and often more, effective. (1,2) Studies estimate that more than 12% of all ambulatory visits in the United States result in an antibiotic prescription, and 23% to 30% of these prescriptions are "inappropriate. (3,4) based on their assigned diagnosis. (3,4) Increasing attention has been paid to antibiotic stewardship efforts in the outpatient setting: in 2016, the CDC outlined core elements of outpatient antibiotic stewardship programs (ASPs). (5) In 2020, the Joint Commission, a nonprofit accreditation organization, implemented ASP requirements for outpatient accreditation. (6)

Behavioral motivations for antibiotic overuse are complex and have not been a focus of medical research until recently. Three motivations that affect outpatient clinician practice warrant further attention: 1) risk aversion, 2) action bias, and 3) patient satisfaction (Table). Existing strategies to address overuse have taken many forms, including clinician education, prospective audit-and-feedback programs, and preauthorization for restricted antibiotics. (14) These interventions have been primarily used in the inpatient setting and are more difficult to implement in outpatient practices. Novel strategies focused on restructuring the decision-making environment, a practice known as choice architecture, may play a complementary role in addressing antibiotic overuse without reducing clinician autonomy. These methods show promise as effective strategies in the current campaign against antibiotic resistance.

CLINICIAN PRACTICES REGARDING ANTIBIOTIC PRESCRIBING

Risk Aversion: Immediacy Effect and the Tragedy of the Commons

Immediacy effect refers to a powerful motivator of human behavior in which individuals value immediate consequences more strongly than delayed consequences. The immediacy effect motivates antibiotic overuse when a clinician is more concerned about the immediate risks of untreated infection than the long-term risks of antibiotic resistance. In circumstances where a patient's syndrome is caused by bacterial infection, the potential harms of nontreatment (ie, worsening infection, hospitalization, and sepsis) become apparent in the shortterm and are directly borne by the patient, family, physician, and care team. Conversely, the harms of antibiotic overuse are often neither immediate nor visible. In the case of drug resistance, the harms are not only delayed but also distributed over the entire medical system. Therefore, even when the likelihood of bacterial infection is low, clinicians who only consider their immediate circumstances have little incentive to restrict antibiotic use: they accrue the benefits of antibiotic overuse by averting the risk of clinical decompensation no matter how small that risk...

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Gale Document Number: GALE|A657476719