As more bacteria develop resistance against the antibiotics available to treat them, healthcare workers struggle to fight back, particularly when it comes to antibiotic prescribing. Many of the antimicrobial stewardship programs call for a reduction in inappropriate prescribing; however, in order to successfully meet this goal, current behaviors need to change.
At the Society of Infectious Disease Pharmacists (SIDP) Program at ASM Microbe Society Day in New Orleans, Louisiana, Conan MacDougall, PharmD, MAS, BCPS-AQ ID, Professor of Clinical Pharmacy, University of California San Francisco School of Pharmacy, took a close look at behavior change interventions and what works when it comes to improving prescribing practices.
Early on in his presentation he shared two psychological concepts that are “powerfully at play” when it comes to antimicrobial stewardship. The first is loss aversion
, which means that individuals tend to prefer avoiding losses more so than “gaining gains.” He illustrated the concept using the example of offering someone $25 now, or flipping a coin (where if it landed on heads, he would give $100, but if it landed on tails they would have to give him $150). It turns out, individuals are more likely to just take the $25.
He explained, “Even though you [might] gain money, many people when presented with these types of scenarios, are averse to losing something, and so, they typically don’t take the bet. So, there’s this idea that the preference for avoiding losses is sort of psychologically more powerful than that of gaining gains.”
He introduced another important concept with another clever scenario. This time he offered $5 now, or $20 tomorrow. He mentioned that if the individual trusted them perhaps they would wait for more money the next day, but would they wait a week? A month? A year? He said, “$20 is $20, it’s four times more than $5, but [the value that people] attach to things tends to decrease with the amount of time until it’s given to them.” This concept is known as future discounting
, which means that “you’re essentially willing to give up value in order to get something sooner.”
So, how does this tie back to antibiotic stewardship? Many physicians and prescribers are troubled by loss aversion. If their patient has a bad outcome due to not receiving antibiotics, they consider that “a significant loss.” He mentioned that the benefits of being more careful when it comes to prescribing (i.e. reducing antibiotic resistance) are more long-term. Although prescribers want to “preserve antibiotics for future generations, future discounting kicks in and they are not really as compelled.”
These concepts have been noted in infectious disease literature. In one of the studies that Dr. MacDougall shared, aspects related to future discounting are apparent. In the study
, physicians were given a scenario (picking an antibiotic for a patient with community-acquired pneumonia), and were then asked to arrange factors (efficacy of drug in treating the condition, patient severity of illness, previous experience/knowledge about drug, potential side effects, ease of use, cost to patient, not wanting to contribute to problem of antibiotic resistance) in terms of importance. Their findings? “Things that were immediate and of risk to the patient were ranked highly, and risk of contributing to the problem of antibiotic resistance was last on their list of things that they said were important, even below costs to patient.” This means that even though physicians are aware of the problem of antibiotic resistance, “there’s a disconnect between people’s self-professed attitudes about preserving antibiotics and how they actually behave in the moment.”