The effectiveness of repeating a social norm feedback intervention to high prescribers of antibiotics in general practice: a national regression discontinuity design

Abstract

Objectives Unnecessary antibiotic prescribing contributes to antimicrobial resistance. A randomized controlled trial in 2014–15 showed that a letter from England’s Chief Medical Officer (CMO) to high-prescribing GPs, giving feedback about their prescribing relative to the norm, decreased antibiotic prescribing. The CMO sent further feedback letters in succeeding years. We evaluated the effectiveness of the repeated feedback intervention. Methods Publicly available databases were used to identify GP practices whose antibiotic prescribing was in the top 20% nationally (the intervention group). In April 2017, GPs in every practice in the intervention group (n=1439) were sent a letter from the CMO. The letter stated that, ‘the great majority of practices in England prescribe fewer antibiotics per head than yours’. Practices in the control group received no communication (n=5986). We used a regression discontinuity design to evaluate the intervention because assignment to the intervention condition was exogenous, depending on a ‘rating variable’. The outcome measure was the average rate of antibiotic items dispensed from April 2017 to September 2017. Results The GP practices who received the letter changed their prescribing rates by −3.69% (95% CI=−2.29 to −5.10; P<0.001), representing an estimated 124 952 fewer antibiotic items dispensed. The effect is robust to different specifications of the model. Conclusions Social norm feedback from a high-profile messenger continues to be effective when repeated. It can substantially reduce antibiotic prescribing at low cost and on a national scale. Therefore, it is a worthwhile addition to antimicrobial stewardship programmes.

Primary care physicians’ attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study

“…12 However, while physicians remain hesitant about the approach of tracking and reporting antibiotic use, studies from the USA and UK have shown that this stewardship approach is effective at reducing inappropriate prescribing. [43][44][45][46][47] Additional studies have evaluated physician perceptions of broader quality measurement systems. One study of US physicians in three states found that 71% felt that paediatric quality reports were effective at improving paediatric care.…”

“… 12 However, while physicians remain hesitant about the approach of tracking and reporting antibiotic use, studies from the USA and UK have shown that this stewardship approach is effective at reducing inappropriate prescribing. 43–47 …”

Provision of social-norms feedback to general practices whose antibiotic prescribing is increasing: a national randomized controlled trial

“…Prescribing was decreasing in both trial arms over the outcome period from March 2018 to September 2018 (β < −0.01, p < 0.001). The lack of effect of the intervention was surprising, given the evidence of effectiveness of previous social-norms-feedback letters to GPs in the UK (Hallsworth et al 2016;Ratajczak et al 2019) and internationally (Behavioural Economics Team of the Australian Government 2018; HSC Public Health Agency 2017).…”

“…Based on this evidence, similar letters were sent out to all practices whose prescribing was in the top 20% nationally in 2015/16 and 2016/ 17 (the NHS Local Area Teams, which were used in the original letter, had been disbanded). An evaluation of the 2016/17 letter using a regression discontinuity design showed that the letter continued to have an effect, causing a 3.69% reduction in prescribing, with an estimated 124,952 fewer antibiotic items dispensed (Ratajczak et al 2019). The intervention has also been successfully implemented in Ireland and Australia (Behavioural Economics Team of the Australian Government 2018; HSC Public Health Agency 2017).…”

Over-the-counter sales of antibiotics for human use in India: The challenges and opportunities for regulation

“…The intervention has supported GPs to reduce their prescribing further by providing feedback on practice prescribing rates, offering encouragement and suggesting practical actions in a clear and succinct manner. 118 Governments may also introduce financial incentives to reduce prescription of antibiotics. For instance, in 2015, NHS England introduced rewards to clinical commissioning groups for a percentage reduction in antibiotic prescribing.…”