Open Access Open Badges Study protocol

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01] - study protocol and baseline practice and provider characteristics

Stephen D Persell1*, Mark W Friedberg2, Daniella Meeker3, Jeffrey A Linder4, Craig R Fox5, Noah J Goldstein5, Parth D Shah6, Tara K Knight7 and Jason N Doctor7

Author Affiliations

1 Division of General Internal Medicine and Geriatrics, Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, 60611, Chicago, IL, USA

2 RAND, 20 Park Plaza, Suite 920, Boston, MA 02116, USA

3 RAND, 1776 Main St., Santa Monica, CA 9040, USA

4 Division of General Medicine and Primary Care, Brigham and Women’s Hospital; Harvard Medical School, Boston, MA 02116, USA

5 Department of Psychology, UCLA Anderson School of Management, David Geffen School of Medicine at UCLA, 110 Westwood Plaza D-511, Los Angeles, CA 90095, USA

6 Department of Health Behavior, UNC Gillings School of Global Public Health, 308 Rosenau Hall, Campus Box 7440, Chapel Hill, NC 27599-7440, USA

7 Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa Street, Unit A, Los Angeles, CA 90089-7273, USA

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BMC Infectious Diseases 2013, 13:290  doi:10.1186/1471-2334-13-290

Published: 27 June 2013



Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians.


The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease.


The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics.

Trials registration NCT01454947

Antibiotics; Acute respiratory infections; Behavioral economics; Social psychology; Clinical decision support