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

Daneman, Nick; Lee, Samantha; Bai, Heming; Bell, Chaim M.; Bronskill, Susan E.; Campitelli, Michael A.; Dobell, Gail; Fu, Longdi; Garber, Gary; Ivers, Noah; Kumar, Matthew; Lam, Jonathan; Langford, Bradley J; Laur, Celia; Morris, Andrew M.; Mulhall, Cara; Pinto, Ruxandra; Saxena, Farah E; Schwartz, Kevin L; Brown, Kevin A.

doi:10.1093/ofid/ofac111

Cited by 5 publications

(1 citation statement)

References 32 publications

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“…Previous studies that have increased the number of mailings, or modified introductory emails, have had no or minimal impact. 11 33 However, our significant findings were observed despite this low engagement with the intervention. Further research on ways to improve engagement with feedback reports should be a priority because this change may result in larger effect sizes.…”

Section: Discussionmentioning

confidence: 63%

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

Schwartz,

Shuldiner,

Langford

et al. 2024

BMJ

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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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Section: Discussionmentioning

confidence: 63%

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

Schwartz,

Shuldiner,

Langford

et al. 2024

BMJ

View full text Add to dashboard Cite

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

Conlin,

Hamard,

Agrinier

et al. 2024

Clinical Microbiology and Infection

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

Onwubiko,

Mehta,

Wiley

et al. 2024

ASHE

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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.

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

Cited by 5 publications

References 32 publications

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

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

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

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