Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial

Effect of a Feedback Visit and a Clinical Decision Support System Based on Antibiotic Prescription Audit in Primary Care: Multiarm Cluster-Randomized Controlled Trial

BACKGROUND

While numerous antimicrobial stewardship programs aim to decrease inappropriate antibiotic prescriptions, evidence of their positive impact is needed to optimize future interventions.

OBJECTIVE

This study aimed to evaluate 2 multifaceted antibiotic stewardship interventions for inappropriate systemic antibiotic prescription in primary care.

METHODS

An open-label, cluster-randomized controlled trial of 2501 general practitioners (GPs) working in western France was conducted from July 2019 to January 2021. Two interventions were studied: the standard intervention, consisting of a visit by a health insurance representative who gave prescription feedback and provided a leaflet for treating cystitis and tonsillitis; and a clinical decision support system (CDSS)-based intervention, consisting of a visit with prescription feedback and a CDSS demonstration on antibiotic prescribing. The control group received no intervention. Data on systemic antibiotic dispensing was obtained from the National Health Insurance System (Système National d'Information Inter-Régimes de l'Assurance Maladie) database. The overall antibiotic volume dispensed per GP at 12 months was compared between arms using a 2-level hierarchical analysis of covariance adjusted for annual antibiotic prescription volume at baseline.

RESULTS

Overall, 2501 GPs were randomized (n=1099, 43.9% women). At 12 months, the mean volume of systemic antibiotics per GP decreased by 219.2 (SD 61.4; 95% CI -339.5 to -98.8; P<.001) defined daily doses in the CDSS-based visit group compared with the control group. The decrease in the mean volume of systemic antibiotics dispensed per GP was not significantly different between the standard visit group and the control group (-109.7, SD 62.4; 95% CI -232.0 to 12.5 defined daily doses; P=.08).

CONCLUSIONS

A visit by a health insurance representative combining feedback and a CDSS demonstration resulted in a 4.4% (-219.2/4930) reduction in the total volume of systemic antibiotic prescriptions in 12 months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04028830; https://clinicaltrials.gov/study/NCT04028830.

Derivation of a risk-adjusted model to predict antibiotic prescribing among hospitalists in an academic healthcare network

Background

Among inpatients, peer-comparison of prescribing metrics is challenging due to variation in patient-mix and prescribing by multiple providers daily. We established risk-adjusted provider-specific antibiotic prescribing metrics to allow peer-comparisons among hospitalists.

Methods

Using clinical and billing data from inpatient encounters discharged from the Hospital Medicine Service between January 2020 through June 2021 at four acute care hospitals, we calculated bimonthly (every two months) days of therapy (DOT) for antibiotics attributed to specific providers based on patient billing dates. Ten patient-mix characteristics, including demographics, infectious disease diagnoses, and noninfectious comorbidities were considered as potential predictors of antibiotic prescribing. Using linear mixed models, we identified risk-adjusted models predicting the prescribing of three antibiotic groups: broad spectrum hospital-onset (BSHO), broad-spectrum community-acquired (BSCA), and anti-methicillin-resistant Staphylococcus aureus (Anti-MRSA) antibiotics. Provider-specific observed-to-expected ratios (OERs) were calculated to describe provider-level antibiotic prescribing trends over time.

Results

Predictors of antibiotic prescribing varied for the three antibiotic groups across the four hospitals, commonly selected predictors included sepsis, COVID-19, pneumonia, urinary tract infection, malignancy, and age >65 years. OERs varied within each hospital, with medians of approximately 1 and a 75th percentile of approximately 1.25. The median OER demonstrated a downward trend for the Anti-MRSA group at two hospitals but remained relatively stable elsewhere. Instances of heightened antibiotic prescribing (OER >1.25) were identified in approximately 25% of the observed time-points across all four hospitals.

Conclusion

Our findings indicate provider-specific benchmarking among inpatient providers is achievable and has potential utility as a valuable tool for inpatient stewardship efforts.

Process evaluation of two large randomized controlled trials to understand factors influencing family physicians' use of antibiotic audit and feedback reports

BACKGROUND

Unnecessary antibiotic prescriptions in primary care are common and contribute to antimicrobial resistance in the population. Audit and feedback (A&F) on antibiotic prescribing to primary care can improve the appropriateness of antibiotic prescribing, but the optimal approach is uncertain. We performed two pragmatic randomized controlled trials of different approaches to audit and feedback. The trial results showed that A&F was associated with significantly reducing antibiotic prescribing. Still, the effect size was small, and the modifications to the A&F interventions tested in the trials were not associated with any change. Herein, we report a theory-informed qualitative process evaluation to explore potential mechanisms underlying the observed effects.

METHODS

Ontario family physicians in the intervention arms of both trials who were sent A&F letters were invited for one-on-one interviews. Purposive sampling was used to seek variation across interested participants in personal and practice characteristics. Qualitative analysis utilized inductive and deductive techniques informed by the Clinical Performance Feedback Intervention Theory.

RESULTS

Modifications to the intervention design tested in the trial did not alter prescribing patterns beyond the changes made in response to the A&F overall for various reasons. Change in antibiotic prescribing in response to A&F depended on whether it led to the formation of specific intentions and whether those intentions translated to particular behaviours. Those without intentions to change tended to feel that their unique clinical context was not represented in the A&F. Those with intentions but without specific actions taken tended to express a lack of self-efficacy for avoiding a prescription in contexts with time constraints and/or without an ongoing patient relationship. Many participants noted that compared to overall prescribing, A&F on antibiotic prescription duration was perceived as new information and easily actionable.

CONCLUSION

Our findings indicate that contextual factors, including the types of patients and the setting where they are seen, affect how clinicians react to audit and feedback. These results suggest a need to test tailored feedback reports that reflect the context of how, where, and why physicians prescribe antibiotics so that they might be perceived as more personal and more actionable.

TRIAL REGISTRATION

Clinical Trial registration IDs: NCT04594200, NCT05044052.

Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review

BACKGROUND

Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs.

OBJECTIVES

We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies.

METHODS

A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach.

RESULTS

The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills.

CONCLUSIONS

Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.

Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia

BACKGROUND

Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target.

METHODS

In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card.

RESULTS

Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card.

CONCLUSIONS

A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.

Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review

BACKGROUND

The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context.

OBJECTIVES

This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness.

DATA SOURCES

Electronic databases until April 2022.

STUDY ELIGIBILITY CRITERIA

Articles covering implementation of AMS interventions in LTCFs.

ASSESSMENT OF RISK OF BIAS

Mixed Methods Appraisal Tool for empirical studies.

METHODS OF DATA SYNTHESIS

Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study.

RESULTS

Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation.

CONCLUSIONS

The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.

What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research

Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.

Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review

BACKGROUND

Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals' behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale.

METHODS

This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS).

RESULTS

From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability.

CONCLUSION

A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability.

TRIAL REGISTRATION

Registered with Prospero in May 2022. CRD42022332606.

Antibiotic Selection and Duration for Catheter-Associated Urinary Tract Infection in Non-Hospitalized Older Adults: A Population-Based Cohort Study

Background

We sought to evaluate the impact of antibiotic selection and duration of therapy on treatment failure in older adults with catheter-associated urinary tract infection (CA-UTI).

Methods

We conducted a population-based cohort study comparing antibiotic treatment options and duration of therapy for non-hospitalized adults aged 66 and older with presumed CA-UTI (defined as an antibiotic prescription and an organism identified in urine culture in a patient with urinary catheterization documented within the prior 90 d). The primary outcome was treatment failure, a composite of repeat urinary antibiotic prescribing, positive blood culture with the same organism, all-cause hospitalization or mortality, within 60 days. We determined the risk of treatment failure accounting for age, sex, comorbidities, and healthcare exposure using log-binomial regression.

Results

Of 4,436 CA-UTI patients, 2,709 (61.1%) experienced treatment failure. Compared to a reference of TMP-SMX (61.9% failure), of those treated with fluoroquinolones, 56.3% experienced failure (RR 0.91, 95% CI: 0.85-0.98) and 60.9% of patients treated with nitrofurantoin experienced failure (RR 1.02, 95% CI: 0.94-1.10). Compared to 5-7 days of therapy (treatment failure: 59.4%), 1-4 days was associated with 69.5% failure (RR 1.15, 95% CI: 1.05-1.27), and 8-14 days was associated with a 62.0% failure (RR 1.05, 95% CI: 0.99-1.11).

Conclusions

Although most treatment options for CA-UTI have a similar risk of treatment failure, fluoroquinolones, and treatment durations ≥ 5 days in duration appear to be associated with modestly improved clinical outcomes. From a duration of therapy perspective, this study provides reassurance that relatively short courses of 5-7 days may be reasonable for CA-UTI.

Regional and national antimicrobial stewardship activities: a survey from the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN)

Background

Antibiotic overuse and misuse in primary care are common, highlighting the importance of antimicrobial stewardship (AMS) efforts in this setting. Audit and feedback (A&F) interventions can improve professional practice and performance in some settings.

Objectives and methods

To leverage the expertise from international members of the Joint Programming Initiative on Antimicrobial Resistance - Primary care Antibiotic Audit and feedback Network (JPIAMR-PAAN). Network members all have experience of designing and delivering A&F interventions to reduce inappropriate antibiotic prescribing in primary care settings. We aim to introduce the network and explore ongoing A&F activities in member regions. An online survey was administered to all network members to collect regional information.

Results

Fifteen respondents from 11 countries provided information on A&F activities in their country, and national/regional antibiotic stewardship programmes or policies. Most countries use electronic medical records as the primary data source, antibiotic appropriateness as the main outcome of feedback, and target GPs as the prescribers of interest. Funding sources varied across countries, which could influence the frequency and quality of A&F interventions. Nine out of 11 countries reported having a national antibiotic stewardship programme or policy, which aim to provide systematic support to ongoing AMS efforts and aid sustainability.

Conclusions

The survey identified gaps and opportunities for AMS efforts that include A&F across member countries in Europe, Canada and Australia. JPIAMR-PAAN will continue to leverage its members to produce best practice resources and toolkits for antibiotic A&F interventions in primary care settings and identify research priorities.

The Effectiveness of Interactive Dashboards to Optimise Antibiotic Prescribing in Primary Care: A Systematic Review

Governments and healthcare organisations collect data on antibiotic prescribing (AP) for surveillance. This data can support tools for visualisations and feedback to GPs using dashboards that may prompt a change in prescribing behaviour. The objective of this systematic review was to assess the effectiveness of interactive dashboards to optimise AP in primary care. Six electronic databases were searched for relevant studies up to August 2022. A narrative synthesis of findings was conducted to evaluate the intervention processes and results. Two independent reviewers assessed the relevance, risk of bias and quality of the evidence. A total of ten studies were included (eight RCTs and two non-RCTs). Overall, seven studies showed a slight reduction in AP. However, this reduction in AP when offering a dashboard may not in itself result in reductions but only when combined with educational components, public commitment or behavioural strategies. Only one study recorded dashboard engagement and showed a difference of 10% (95% CI 5% to 15%) between intervention and control. None of the studies reported on the development, pilot or implementation of dashboards or the involvement of stakeholders in design and testing. Interactive dashboards may reduce AP in primary care but most likely only when combined with other educational or behavioural intervention strategies.

Effects of social norm feedback on antibiotic prescribing and its characteristics in behaviour change techniques: a mixed-methods systematic review

Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system.

Antibiotic prescribing and antimicrobial stewardship in long-term care facilities: Past interventions and implementation challenges

Background

The threat of antimicrobial resistance (AMR) is rising, leading to increased illness, death and healthcare costs. In long-term care facilities (LTCFs), high rates of infection coupled with high antibiotic use create a selective pressure for antimicrobial-resistant organisms that pose a risk to residents and staff as well as surrounding hospitals and communities. Antimicrobial stewardship (AMS) is paramount in the fight against AMR, but its adoption in LTCFs has been limited.

Methods

This article summarizes factors influencing antibiotic prescribing decisions in LTCFs and the effectiveness of past AMS interventions that have been put in place in an attempt to support those decisions. The emphasis of this literature review is the Canadian LTCF landscape; however, due to the limited literature in this area, the scope was broadened to include international studies.

Results

Prescribing decisions are influenced by the context of the individual patient, their caregivers, the clinical environment, the healthcare system and surrounding culture. Antimicrobial stewardship interventions were found to be successful in LTCFs, though there was considerable heterogeneity in the literature.

Conclusion

This article highlights the need for more well-designed studies that explore innovative and multifaceted solutions to AMS in LTCFs.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in Non-Hospital Care Settings in 2021

The scope of antimicrobial stewardship programs has expanded beyond the acute hospital setting. The need to optimize antimicrobial use in emergency departments, urgent, primary, and specialty care clinics, nursing homes, and long-term care facilities prompted the development of core elements of stewardship programs in these settings. Identifying the most innovative and well-designed stewardship literature in these novel stewardship areas can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network evaluated antimicrobial stewardship-related, peer-reviewed literature published in 2021 that detailed actionable interventions specific to the nonhospital setting. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for expansion of antimicrobial stewardship programs beyond the acute hospital setting.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: −0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: −0.8, p < 0.001); and doxycycline (−0.2, p = 0.005) and penicillin (−0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

Behavioral Nudges to Improve Audit and Feedback Report Opening among Antibiotic Prescribers: A Randomized Controlled Trial

Background

Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested three behavioral nudging techniques delivered by email to improve report opening.

Methods

We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions.

Results

The trial included 421 physicians caring for more than 28,000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio (OR) 1.51 (95%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR 1.62, 95%CI 1.06-2.47, p=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p&lt;0.001).

Conclusions

Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.

Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations

Background

Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad.

Methods

We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health (“OH Trial”). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario (“PHO Trial”). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization.

Discussion

This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care.

Trial registration

NCT04594200, NCT05044052. CIHR Grant ID: 398514

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01194-8.