A USC and Duke University study finds that a persistent "know-do gap," where clinicians know guidelines but practice differently, is the primary driver of antibiotic overprescribing in India's private sector - not lack of knowledge, point-of-sale profits or shortages of clinically recommended treatments.
The study appeared this month in Science Advances.
Researchers hope the study will help them find ways to reduce the inappropriate use of antibiotics and fight the global health threat of antibiotic resistance. A related study published last year found a similar know-do gap in the underutilization of oral rehydration salts, the standard of care for childhood diarrhea.
In this experiment, a sample of 2,282 private providers across 253 towns, 70% prescribed antibiotics without signs of bacterial infection, and among those who knew antibiotics were inappropriate, 62% still prescribed them to standardized patients, indicating a large know-do gap.
The study found that closing the know-do gap could reduce inappropriate antibiotic use by roughly 30 percentage points.
Randomized experiments showed that the know-do gap was driven by providers' beliefs about patient preferences and not profits from selling antibiotics or, in the case of childhood diarrhea, limited supplies of oral rehydration salts.
When patients expressed a preference for oral rehydration salts, inappropriate antibiotic use fell by 17 percentage points on average, with especially large reductions among pharmacies. By contrast, removing point-of-sale financial incentives and supplying oral rehydration salts had no meaningful effect on antibiotic prescribing.
A choice experiment with 1,189 caregivers further found that patients did not prefer providers who give antibiotics over those who provide oral rehydration salts, underscoring the misalignment between provider perceptions and actual patient preferences.
Knowing one thing, doing another
"Our data reveal a striking disconnect: Clinicians know antibiotics are wrong for most diarrhea cases, yet they prescribe them anyway because they think parents expect 'strong' medicines," said corresponding author Zachary Wagner of the Center for Economic and Social Research at the USC Dornsife College of Letters, Arts and Sciences. "Correcting that perception offers the biggest win for global antibiotic stewardship."
"A lot of children are given antibiotics when they don't need them, and that can lead to drug-resistant bacteria - a problem for the whole world, not just India," said co-author Neeraj Sood of the USC Schaeffer Center for Health Policy & Economics and the USC Price School of Public Policy. "By showing that patient-provider communication trumps financial motives, we give policymakers a laser-focused lever: help doctors understand real patient preferences."
The authors note that the largest know-do gaps were among less formally trained providers and pharmacies, where preference signaling by patients yielded the biggest improvements, suggesting targeted interventions could deliver outsize benefits.
"Pharmacies and informal providers, often the first stop for care, showed the largest know-do gaps," noted co-author Manoj Mohanan of Duke University. "Interventions that empower caregivers to voice a preference for oral rehydration salts, or public campaigns signaling that parents don't demand antibiotics, could slash misuse at scale."
About this study: In addition to Wagner, Sood and Mohanan, other authors of the study include Somalee Banerjee of Kaiser Permanente in Oakland; Jagadish Krishnappa and Sumeet Patil of NEERMAN in New Delhi, India; Arnab Mukherji of the Indian Institute of Management in Bengaluru; and Rushil Zutshi of the National Bureau of Economic Research.
The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (5R01DK126049).
