Bacteria resistant to antibiotic therapy accounted for an estimated 94,000 life-threatening infections and over 18,500 deaths in 2005, more deaths than from AIDS that year (Klevens et al. 2007). Resistant bacterial strains have been linked to aggressive antibiotic prescribing. Acute respiratory infections (ARIs) are a high frequency primary care problem for which antibiotics prescriptions are often unwarranted. Standard attempts to influence physician behavior using economic incentives (i.e., pay-for-performance) have had limited success, are costly, and rarely persist after the intervention ends. Behavioral economics may improve treatment of ARIs in a sustained way by appealing to providers'self-image. First, we propose to study the impact of enhanced defaults, in which alternatives to antibiotics are the presumed course of action and use of antibiotics must be explicitly justified. Numerous studies have found that alternatives are much more popular when they are designated the default. Second, we will study social norms, in which we present health care providers with feedback on their own behavior, the behavior of a group of successful peers who rarely prescribe inappropriate antibiotics (descriptive norm), and the recommended guidelines (injunctive norm). Numerous studies have shown that people strive to conform to such norms. Finally, we will study providing salient alternatives to antibiotics in electronic health records, prompting providers to explicit state their preferences for them, and informing them of the (high) proportion of colleagues who also prefer them. We propose to apply these principles at the point-of-care in a 2 x 2 x 2 factorial cluster randomized trial with 46 diverse clinical sites across the United States. Clinics will be randomized to education plus care provision with and without an enhanced default, social norm, and alternative prescribing interventions. The long-term objective is to develop a set of applied behavioral economic tools that are effective in prompting providers to adhere to guidelines in infection treatment, and which may have application in other areas of health care delivery. The success of this project will result in: 1) increased patient safety through a reduction in inappropriate and overuse of antibiotic therapies;and 2) more efficient and appropriate utilization of health care resources by reducing inappropriate and overuse of antibiotic therapies and decreasing the prevalence of medication resistant infections. PUBLIC HEALTH RELEVANCE: We aim to develop a set of applied behavioral economic tools that are effective in prompting providers to adhere to guidelines in infection treatment and which may have application in other areas of health care delivery. The success of this project will result in: 1) increased patient safety through a reduction in inappropriate and overuse of antibiotic therapies;and 2) more efficient and appropriate utilization of health care resources by reducing inappropriate and overuse of antibiotic therapies and decreasing the prevalence of medication resistant infections.