Cognitive Reflection and Antibiotic Prescribing for Acute Respiratory Infections

BACKGROUND: Variation in clinical decision-making could be explained by clinicians' tendency to make 'snap-decisions' versus making more reflective decisions. One common clinical decision with unexplained variation is the prescription of antibiotics for acute respiratory infections (ARIs). OBJECTIVE: We hypothesized that clinicians who tended toward greater cognitive reflection would be less likely to prescribe antibiotics for ARIs. METHODS: The Cognitive Reflection Test (CRT) is a psychological test with three questions with intuitive but incorrect answers that respondents reach if they do not consider the question carefully. The CRT is scored from 0 to 3, representing the number of correct answers. A higher score indicates greater cognitive reflection. We administered the CRT to 187 clinicians in 50 primary care practices. From billing and electronic health record data, we calculated clinician-level antibiotic prescribing rates for ARIs in 3 categories: all ARIs, antibiotic-appropriate ARIs and non-antibiotic-appropriate ARIs. RESULTS: A total of 57 clinicians (31%) scored 0 points on the CRT; 38 (20%) scored 1; 51 (27%) scored 2; and 41 (22%) scored 3. We found a roughly U-shaped association between cognitive reflection and antibiotic prescribing. The antibiotic prescribing rate for CRT scores of 0, 1, 2 and 3 for all ARIs (n = 37080 visits) was 32%, 26%, 25% and 30% (P = 0.10); for antibiotic-appropriate ARIs (n = 11220 visits) was 60%, 55%, 54% and 58% (P = 0.63); and for non-antibiotic-appropriate ARIs (n = 25860 visits) was 21%, 17%, 13% and 18%, respectively (P = 0.03). CONCLUSIONS: In contrast to our hypothesis, there appears to be a 'sweet-spot' of cognitive reflection for antibiotic prescribing for non-antibiotic-appropriate ARIs. Differences in clinicians' cognitive reflection may be associated with other variations in care.