OBJECTIVES: Based on previous research showing that behavioral economics interventions can minimize inappropriate use of antimicrobials for acute respiratory infection (ARI), we sought to determine the cost-effectiveness of these interventions: (1) Suggested Alternatives (SA), which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (2) Accountable Justification (JA), which mandates free-text justification into the patient’s electronic health record when antibiotics are prescribed; and (3) Peer Comparison (PC), which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to peers.

METHODS: We used a 30-year Markov model from the US societal perspective to simulate the utilization of antibiotics, cost of care, and health outcomes among a cohort of 45-year-old adults presenting to a healthcare provider with an ARI and its potential complications. Transition probabilities between disease states, costs, and utility values were derived from the literature and available surveillance data. Discounted total costs, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) of each intervention relative to no intervention were calculated, and sensitivity of these estimates assessed through a series of one-way sensitivity analyses.

RESULTS:  Relative to the status quo, each intervention is cost-effective, as ICERs indicate the dominance of each intervention over current practice (lower costs but higher QALYs). In the base case, total costs for each intervention were $1,004, $519, $487, and $447, and total QALYs were 14.32, 14.39, 14.40, and 14.41 for the control, SA, JA, and PC groups respectively. Dominance was driven by decreased costs for each intervention due to significant decreases in healthcare utilization for antibiotic-associated adverse drug reactions. Results remained robust in one-way sensitivity analyses. Notably, changes in bacterial resistance over time did not have a substantial impact on the results. CONCLUSIONS: Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.