Simplicity Matters—Overengineering Feedback Can Be Counterproductive

Linder, Jeffrey A.; Fox, Craig R.

doi:10.1001/jamainternmed.2022.6528

Cited by 2 publications

(3 citation statements)

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“…A theory put forward by Linder and Fox is that feedback designed to be more subtle and avoid offending physicians may be too vague to elicit the desired behaviour change. 28 Best practice recommendations have been published on optimizing audit and feedback of antibiotics in primary care. 29 Antibiotic audit and feedback should be simple and include a single central figure.…”

Section: Discussionmentioning

confidence: 99%

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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: 99%

“…Data that are too subtle, complex, provide multiple metrics or multiple comparators are less likely to be used by physicians and will not drive behaviour change. 28 29 30 …”

Section: Discussionmentioning

confidence: 99%

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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show abstract

“…The Swiss Ministry of Health also reported higher rates of influenza-like illnesses and invasive Haemophilus influenzae infections during the intervention period of 2018-2019 when compared with 2017. 34 This finding illustrates the importance of evaluating feedback interventions for antibiotic prescribing over sufficiently long periods to accurately account for seasonality effects.…”

Section: Limitations and Strengthsmentioning

confidence: 92%

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

et al. 2023

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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

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Simplicity Matters—Overengineering Feedback Can Be Counterproductive

Abstract: Institut für Infektionskrankheiten. Swiss Centre for Antibiotic Resistance. Accessed May 10, 2022. http://www.anresis.ch 22. Wang B, Ogburn EL, Rosenblum M. Analysis of covariance in randomized trials: more precision and valid confidence intervals, without model assumptions.

Cited by 2 publications

References 7 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

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

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