Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care

Abstract

ImportanceAntibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population.ObjectiveTo investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.Design, Setting, and ParticipantsThis pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022.InterventionsPrimary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial.Main Outcomes and MeasuresThe claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups.ResultsA total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a –0.1% (95% CI, –1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (–0.9% [95% CI, –1.5% to –0.4%]).Conclusions and RelevanceThis randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.Trial RegistrationClinicalTrials.gov Identifier: NCT03379194

Simplicity Matters—Overengineering Feedback Can Be Counterproductive

“…In this issue of JAMA Internal Medicine , Aghlmandi and colleagues report on a randomized clinical trial that shows the challenges of providing effective feedback. These researchers provided feedback to board-certified primary care and pediatric clinicians who were in the top 75th percentile of antibiotic prescribers in Switzerland (n = 3426 physicians).…”

“…For instance, simplifying court summons documents reduced failures to appear in court, 2 simplifying letters to parents reduced truancy rates among school children, 3 and simplifying letters to patients improved rates of colorectal cancer screening. 4 In this issue of JAMA Internal Medicine, Aghlmandi and colleagues 5 report on a randomized clinical trial that shows the challenges of providing effective feedback. These researchers provided feedback to board-certified primary care and pediatric clinicians who were in the top 75th percentile of antibiotic prescribers in Switzerland (n = 3426 physicians).…”

“…The investigators aggregated data from multiple insurers (with attendant delays) and packaged and sent the data about nearly 1.3 million patients repeatedly over 2 years to thousands of physicians. 5 Privacy constraints were challenging. The graph of monthly antibiotic prescribing rates is notable for clearly demonstrating the trial's underlying data over time, the clinical interest of the interquartile ranges, and a depressing lack of change or differences in the antibiotic prescribing rates.…”

“…First, the data were too detailed and lacked a clear summative statement about how prescribers were doing and what they should be doing differently-the feedback depicted visually where each prescriber fell on a distribution and left it to higher prescribers to figure out that their performance was worse than average and what specific actions they should take to improve. 5 Moreover, these data were only provided quarterly and were lagged by several months. Second, the data referenced a large, diffuse peer group that physicians were presumably not closely identified with, keyed off average overall prescribing rates (rather than, for example, diagnosis-inappropriate prescribing relative to topperforming peers).…”

“…7 Plainly stated: details matter. In a related vein, those designing and providing systematic feedback on clinical performance-investigators, health insurers, health systems, and others-should take the cautionary lessons from the trial by Aghlmandi and colleagues 5 to heart. To induce behavior change, feedback messages must be distilled into their most essential elements so they command attention, are easily understood, and can be readily acted on in an efficacious way.…”