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Nudging Guideline-concordant Antibiotic Prescribing Using Public Commitments

This study has been completed.
National Institutes of Health (NIH)
National Institute on Aging (NIA)
Information provided by (Responsible Party):
Jason Doctor, University of Southern California Identifier:
First received: January 10, 2013
Last updated: July 5, 2017
Last verified: July 2017
Inappropriate antibiotic prescribing for acute respiratory infections (ARIs) persists despite decades of intervention efforts. Negative outcomes of inappropriate antibiotics include increased costs of care, adverse drug reactions, and rising prevalence of antibiotic-resistant bacteria. To address this public health problem, we apply the principles of commitment and consistency in an effort to influence clinician decision-making through the implementation of a low-cost behavioral "nudge" in the form of a simple public commitment device. Clinicians were asked to post in their exam room a signed letter indicating their commitments to reducing inappropriate antibiotic use for ARIs. Our hypothesis is that clinicians displaying the poster-sized commitment letters will decrease their inappropriate antibiotic prescribing for ARIs as compared to clinicians in the control condition (with no posted letter).

Condition Intervention
Acute Respiratory Infections (ARIs) Other: Posted commitment letter

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Nudging Guideline-concordant Antibiotic Prescribing Using Public Commitments

Resource links provided by NLM:

Further study details as provided by Jason Doctor, University of Southern California:

Primary Outcome Measures:
  • Inappropriate Antibiotic Prescribing for Patients With Acute Respiratory Infections (ARI) [ Time Frame: up to 12 months post intervention ]
    Using data from electronic health records, we will calculate clinician antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses: acute nasopharyngitis (ICD-9 460.x), acute laryngitis without obstruction (465.8), acute laryngopharyngitis (465.0), acute bronchitis (466.x), acute upper respiratory infections of other multiple sites (465.8), acute upper respiratory infections not otherwise specified (465.9), bronchitis not specified as acute or chronic (490.x), non-streptococcal pharyngitis (462.xx), and influenza with other respiratory manifestations (487.1). To control for temporal trends in antibiotic prescribing and provider-fixed effects, we will fit a logistic mixed effects model that predicts inappropriate antibiotic prescribing as a function of study arm and an indicator for baseline versus intervention period (a difference-in-differences regression).

Enrollment: 14
Study Start Date: February 2012
Study Completion Date: May 2013
Primary Completion Date: May 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Posted commitment letter
The poster-sized (18x24 inches) commitment letter, written at the 8th grade reading-level and displayed in English and Spanish, emphasize clinician commitment to guidelines for appropriate antibiotic prescribing and explain why antibiotics are not appropriate in many cases. These letters, featuring clinician photographs and signatures, are displayed in clinician exam rooms for a 16-week period.
Other: Posted commitment letter
No Intervention: Control
Usual care with no posted letters.


Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Medical professionals licensed to provide care and prescribe medications (including antibiotics)
  • Treating adult patients (18 years of age and older) from 5 Los Angeles community clinics

Exclusion Criteria:

  Contacts and Locations
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Please refer to this study by its identifier: NCT01767064

United States, California
QueensCare Family Clinics
Los Angeles, California, United States, 90027
Sponsors and Collaborators
University of Southern California
National Institutes of Health (NIH)
National Institute on Aging (NIA)
Principal Investigator: Jason N Doctor, Ph.D. University of Southern California
  More Information

Publications automatically indexed to this study by Identifier (NCT Number):
Responsible Party: Jason Doctor, Associate Professor, University of Southern California Identifier: NCT01767064     History of Changes
Other Study ID Numbers: USCalifornia
RC4AG039115 ( U.S. NIH Grant/Contract )
Study First Received: January 10, 2013
Results First Received: March 30, 2017
Last Updated: July 5, 2017

Keywords provided by Jason Doctor, University of Southern California:
ARIs, antibiotics, public commitment, quality improvement

Additional relevant MeSH terms:
Respiratory Tract Infections
Respiratory Tract Diseases
Anti-Bacterial Agents
Antibiotics, Antitubercular
Anti-Infective Agents
Antitubercular Agents processed this record on September 21, 2017