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Schwartz KL, Shuldiner J, Langford BJ, Brown KA, Schultz SE, Leung V, Daneman N, Tadrous M, Witteman HO, Garber G, Grimshaw JM, Leis JA, Presseau J, Silverman MS, Taljaard M, Gomes T, Lacroix M, Brehaut J, Thavorn K, Gushue S, Friedman L, Zwarenstein M, Ivers N. Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial. BMJ 2024; 385:e079329. [PMID: 38839101 PMCID: PMC11151833 DOI: 10.1136/bmj-2024-079329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms. DESIGN Pragmatic, factorial randomised controlled trial. SETTING Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial. INTERVENTION A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics. MAIN OUTCOME MEASURES Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression. RESULTS 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)). CONCLUSIONS Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT04594200.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Bradley J Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada
- Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Gary Garber
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
| | - Jeremy M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Jerome A Leis
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Tara Gomes
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Meagan Lacroix
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | | | - Merrick Zwarenstein
- Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Noah Ivers
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Michalsen BO, Xu AXT, Alderson SL, Bjerrum L, Brehaut J, Bucher HC, Clarkson J, Duncan E, Grimshaw J, Gunnarsson R, Høye S, Ivers N, Lecky DM, Lindbæk M, Llor C, Lundgren PT, O’connor D, Pulcini C, Ramsay C, Sundvall PD, Verheij T, Schwartz KL. 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). JAC Antimicrob Resist 2023; 5:dlad048. [PMID: 38659427 PMCID: PMC10123362 DOI: 10.1093/jacamr/dlad048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/27/2023] [Indexed: 04/16/2024] Open
Abstract
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.
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Affiliation(s)
- Benedikte Olsen Michalsen
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Alice X T Xu
- Health Protection, Public Health Ontario, Toronto, Canada
- Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sarah L Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Oaklands Health Centre, Holmfirth, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jamie Brehaut
- Centre for Practice-Changing Research (CPCR), Ottawa Hospital Research Institute, Ottawa, Canada
| | - Heiner C Bucher
- University of Basel, c/o Division of Clinical Epidemiology, Basel, Switzerland
| | - Janet Clarkson
- University of Dundee, NHS Education for Scotland, Dundee, UK
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa Canada Research Chair in Health Knowledge Transfer and Uptake, Ottawa, Canada
| | - Ronny Gunnarsson
- General Practice/Family medicine, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Goteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Sigurd Høye
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Noah Ivers
- Department of Family Medicine, Women’s College Hospital, Toronto, Canada
| | - Donna M Lecky
- Primary Care & Interventions Unit, UK Health Security Agency, Gloucester, UK
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Carl Llor
- Department is University Institute in Primary Care Research, University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Denise O’connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia
| | - Celiné Pulcini
- Public Health Research Unit, Université de Lorraine, APEMAC, Nancy, France
- CHRU-Nancy, Université de Lorraine, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pär-Daniel Sundvall
- General Practice/Family medicine, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Goteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrect, The Netherlands
| | - Kevin L Schwartz
- Health Protection, Public Health Ontario, Toronto, Canada
- Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
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Sutherland S, Born K, Singhal S. Moving the needle on dental antibiotic overuse in Canada post COVID-19. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2022; 48:502-505. [PMID: 38173695 PMCID: PMC10760939 DOI: 10.14745/ccdr.v48i1112a02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antimicrobial resistance due to over-prescribing in health care, including in dentistry, has been acknowledged as one of the top ten threats to global health by the World Health Organization. Dentistry is responsible for approximately 10% of antibiotics prescribed worldwide and research has shown up to 80% of antibiotics prescribed by dentists may be unnecessary. During the early months of the coronavirus disease 2019 pandemic, when dental offices handled only dental emergencies, it is probable that antibiotics were prescribed more readily and for longer duration to defer treatment for non-urgent cases. These unprecedented times strengthened the realization that strong dental antimicrobial stewardship practises are required in Canada to keep antimicrobial overuse under control. In countries, such as the United Kingdom and Australia, significant work is ongoing in this regard. Canada has made progress in developing tools for antimicrobial stewardship specifically for physicians in community settings, where the vast majority of antibiotics are prescribed, and it is now time to pay attention to antimicrobial stewardship in the field of dental care. Investments in developing a national level dental prescription database, along with monitoring, education and feedback mechanisms, can strongly support moving the needle on dentist-driven antibiotic overuse in Canada.
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Affiliation(s)
- Susan Sutherland
- Sunnybrook Health Sciences Centre, Toronto, ON
- Faculty of Dentistry, University of Toronto, Toronto, ON
| | - Karen Born
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON
| | - Sonica Singhal
- Faculty of Dentistry, University of Toronto, Toronto, ON
- Health Promotion, Chronic Disease, and Injury Prevention, Public Health Ontario, Toronto, ON
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