Evaluating the impact of a very low-cost intervention to increase practices’ engagement with data and change prescribing behaviour: a randomized trial in English primary care

Abstract

Background Unsolicited feedback can solicit changes in prescribing. Objectives Determine whether a low-cost intervention increases clinicians’ engagement with data, and changes prescribing; with or without behavioural science techniques. Methods Randomized trial (ISRCTN86418238). The highest prescribing practices in England for broad-spectrum antibiotics were allocated to: feedback with behavioural impact optimization; plain feedback; or no intervention. Feedback was sent monthly for 3 months by letter, fax and email. Each included a link to a prescribing dashboard. The primary outcomes were dashboard usage and change in prescribing. Results A total of 1401 practices were randomized: 356 behavioural optimization, 347 plain feedback, and 698 control. For the primary engagement outcome, more intervention practices had their dashboards viewed compared with controls [65.7% versus 55.9%; RD 9.8%, 95% confidence intervals (CIs): 4.76% to 14.9%, P < 0.001]. More plain feedback practices had their dashboard viewed than behavioural feedback practices (69.1% versus 62.4%); but not meeting the P < 0.05 threshold (6.8%, 95% CI: −0.19% to 13.8%, P = 0.069). For the primary prescribing outcome, intervention practices possibly reduced broad-spectrum prescribing to a greater extent than controls (1.42% versus 1.12%); but again not meeting the P < 0.05 threshold (coefficient −0.31%, CI: −0.7% to 0.1%, P = 0.104). The behavioural impact group reduced broad-spectrum prescribing to a greater extent than plain feedback practices (1.63% versus 1.20%; coefficient 0.41%, CI: 0.007% to 0.8%, P = 0.046). No harms were detected. Conclusions Unsolicited feedback increased practices’ engagement with data, with possible slightly reduced antibiotic prescribing (P = 0.104). Behavioural science techniques gave greater prescribing effects. The modest effects on prescribing may reflect saturation from similar initiatives on antibiotic prescribing. Clinical Trial Registration ISRCTN86418238.

Feedback of Antibiotic Prescribing in Primary Care (FAPPC) trial: results of a real-world cluster randomized controlled trial in Scotland, UK

“…Internationally, large-scale primary care trials of prescribing feedback aiming to reduce total antibiotic use have typically had limited effects, 7–9 , 11 , 12 although one intervention found that added ‘behavioural impact optimization’ had marginal benefit. 8 An Irish intervention achieved a 2%–3% reduction in total prescribing, 10 a similar effect size to the larger English study targeting the highest prescribing practices, 14 but it only included a small number of volunteer practices. Prescribing feedback trials aiming to improve the choice of antibiotic for specific clinical indications in primary care, typically UTI, 13 , 27 , 28 RTI 29–31 or both, 32 , 33 report larger effect sizes of up to 20%.…”

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

“…Implementation of social norm feedback varied between studies (figure 2). Social norm feedback was most commonly: sent to all prescribers (n=11)34 37 40–42 45 46 48 as opposed to the highest prescribers only35 36 38 39 47 50 51; and compared prescribing to the group average (n=12) 34–36 38 40 41 45 47 48 50. Only four studies used an injunctive norm, which also provided positive reinforcement to those performing well 41 44 46 52.…”

“…The effect sizes of social norm feedback interventions on the number of antibiotics/1000 consultations (n=3) ranged from no change45 to a reduction of 13.6% (95% CI 16.6 to 10.6) at 6 months postintervention35; and the number of antibiotic prescriptions/1000 registered population (n=5) from no change51 to an approximate 5% reduction (−58.7/1000 population (95% CI 116.7 to 0.7)) 12-month postintervention 36…”

“…It has been suggested that we can also learn from nudges that fail 14 54. There were four studies that implemented a social norm feedback nudge that had no effect on overall antibiotic prescribing 39 40 45 51. All four studies had two intervention features in common.…”

“…The effect sizes of social norm feedback interventions on the number of antibiotics/1000 consultations (n=3) ranged from no change 45 to a reduction of 13.6% (95% CI 16.6 to 10.6) at 6 months postintervention 35 ; and the number of antibiotic prescriptions/1000 registered population (n=5) from no change 51 to an approximate 5% reduction (−58.7/1000 population (95% CI 116.7 to 0.7)) 12-month postintervention. 36 Studies measuring antibiotic prescribing for specific infection types reported absolute difference effect sizes of −1.2% (95% CI −10.5 to 8.2), 40 −1.7% (p=0.93) 37 and −5.2% (95% CI −6.9 to -1.6) 44 in the proportion of upper RTI treated with an antibiotic; a relative decrease of 9.6% (p=0.0004) 41 in inappropriate antibiotic for UTIs, and lower odds of antibiotic prescribing for RTI (OR: 0.73 (95% CI 0.53 to 0.995)).…”