How ‘decision fatigue’ may lead physicians to prescribe more antibiotics

Physicians tend to write more prescriptions for antibiotics later in the day, according to a review of prescription data by athenahealth, which may be due to a concept called “decision fatigue.”

The analysis examined more than 175,000 interactions between providers and non-elderly adult patients with symptoms of acute respiratory infection (ARI). As the day wore on, doctors became more likely to prescribe antibiotics. By the 13^th appointment, they were 13 percent more likely to write an antibiotic prescription, and 19 percent more likely by the 24^th appointment.

The increase was also noted in appointments involving ARI where antibiotics are never indicated.

Some of the experts commenting on the study said the prescriptions increase may be pinned on “patient negotiation fatigue," rather than having to make many decisions throughout the day, or “decision fatigue.”

“Anecdotally, if you just talk to doctors, most of them will give the impression that they can talk patients out of antibiotics, but it takes more time,” said Ann Thomas, MD, medical director for the Oregon Health Authority’s Alliance Working for Antibiotic Resistance Education (AWARE) program. “So the fatigue is just that wearing down and not being willing to [talk the patients out of it]. When it’s at the end of the day and you’re behind and you’re tired, it’s like, 'OK, I’m just going to give it to them. That’s what they want, and I’m going to get them on their way.'”

The findings in the analysis mirror a 2014 study co-authored by Jeffrey A. Linder of Brigham and Women’s Hospital and published in JAMA Internal Medicine.

“We found that primary care clinicians’ likelihood of prescribing antibiotics for ARIs increased during clinic sessions, consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments,” Linder and co-authors wrote.

The solution, according to David R. Andes, MD, professor of infectious disease at the University of Wisconsin School of Medicine and Public Health, isn’t as simple as seeing fewer patients.

“We know a team approach is best for solving this. Whether front desk folks or education tools that can be marketed to patients are most effective to relieve the burden on the doctor, that remains to be seen,” Andes told athenahealth. “When clinicians [at our hospital] have been made aware of the issues regarding prescription of the wrong antibiotics—or prescription of antibiotics when they aren’t needed—we’ve seen quite a turnaround. A little sunshine helps in this area. When we recognize the prescription of an antibiotic that’s not optimal, we address the clinician immediately.”