. 2024 Jun 5:385:e079329.

doi: 10.1136/bmj-2024-079329.

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

Kevin L Schwartz^{1

2

3

4}, Jennifer Shuldiner^{5

6}, Bradley J Langford^{3

7}, Kevin A Brown^{7

2

3}, Susan E Schultz², Valerie Leung^{7

8}, Nick Daneman^{7

2

6

9}, Mina Tadrous^{2

5

10}, Holly O Witteman^{11

12}, Gary Garber^{13

14}, Jeremy M Grimshaw^{14

15}, Jerome A Leis^{9

13}, Justin Presseau^{15

16}, Michael S Silverman¹⁷, Monica Taljaard^{15

16}, Tara Gomes^{2

4

6

10}, Meagan Lacroix⁵, Jamie Brehaut^{15

16}, Kednapa Thavorn^{2

15

16}, Sharon Gushue¹⁸, Lindsay Friedman⁷, Merrick Zwarenstein¹⁹, Noah Ivers^{2

5

20}

Affiliations

¹ Public Health Ontario, Toronto, ON, Canada kevin.schwartz@oahpp.ca.
² ICES, Toronto, ON, Canada.
³ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
⁴ Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.
⁵ Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
⁶ Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
⁷ Public Health Ontario, Toronto, ON, Canada.
⁸ Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada.
⁹ Sunnybrook Research Institute, Toronto, ON, Canada.
¹⁰ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada.
¹² Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada.
¹³ Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁴ Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
¹⁵ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
¹⁶ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
¹⁷ Western University, London, ON, Canada.
¹⁸ Ontario Health, Toronto, ON, Canada.
¹⁹ Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
²⁰ Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.

PMID: 38839101
PMCID: PMC11151833
DOI: 10.1136/bmj-2024-079329

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

Kevin L Schwartz et al. BMJ. 2024.

. 2024 Jun 5:385:e079329.

doi: 10.1136/bmj-2024-079329.

Authors

Affiliations

¹ Public Health Ontario, Toronto, ON, Canada kevin.schwartz@oahpp.ca.
² ICES, Toronto, ON, Canada.
³ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
⁴ Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.
⁵ Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
⁶ Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
⁷ Public Health Ontario, Toronto, ON, Canada.
⁸ Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada.
⁹ Sunnybrook Research Institute, Toronto, ON, Canada.
¹⁰ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada.
¹² Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada.
¹³ Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁴ Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
¹⁵ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
¹⁶ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
¹⁷ Western University, London, ON, Canada.
¹⁸ Ontario Health, Toronto, ON, Canada.
¹⁹ Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
²⁰ Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.

PMID: 38839101
PMCID: PMC11151833
DOI: 10.1136/bmj-2024-079329

Erratum in

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial.
[No authors listed] [No authors listed] BMJ. 2024 Jun 12;385:q1261. doi: 10.1136/bmj.q1261. BMJ. 2024. PMID: 38866412 Free PMC article. No abstract available.

Abstract

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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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: funding by the Canadian Institute for Health Research; JAL reports financial compensation for expert testimony by the Ontario Hospital Association, Ontario Ministry of the Attorney General, Seneca College and Choosing Wisely Canada. TG reports financial compensation from the Ontario Ministry of Health, Ontario College of Pharmacists, the Canadian Agency for Drugs and Technologies in Health, and Indigenous Services Canada. All other authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

**Fig 1**
Consort diagram of study inclusion and exclusion criteria

**Fig 2**
Monthly antibiotic prescribing rates per 1000 patient visits, by intervention group, January 2019 to January 2023

**Fig 3**
Forest plot of stratified results for antibiotic prescribing rate at six months. Abx=antibiotic

See this image and copyright information in PMC

Comment in

Antimicrobial stewardship.
Powers JH 3rd. Powers JH 3rd. BMJ. 2024 Jun 5;385:q1170. doi: 10.1136/bmj.q1170. BMJ. 2024. PMID: 38839082 No abstract available.

References

1. Murray CJL, Ikuta KS, Sharara F, et al. Antimicrobial Resistance Collaborators . Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022;399:629-55. 10.1016/S0140-6736(21)02724-0 - DOI - PMC - PubMed
1. Schwartz KL, Ivers N, Langford BJ, et al. . Effect of antibiotic-prescribing feedback to high-volume primary care physicians on number of antibiotic prescriptions: a randomized clinical trial. JAMA Intern Med 2021;181:1165-73. 10.1001/jamainternmed.2021.2790 - DOI - PMC - PubMed
1. Aghlmandi S, Halbeisen FS, Saccilotto R, et al. . Effect of antibiotic prescription audit and feedback on antibiotic prescribing in primary care: a randomized clinical trial. JAMA Intern Med 2023;183:213-20. 10.1001/jamainternmed.2022.6529. - DOI - PMC - PubMed
1. Meeker D, Linder JA, Fox CR, et al. . Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315:562-70. 10.1001/jama.2016.0275 - DOI - PMC - PubMed
1. Hallsworth M, Chadborn T, Sallis A, et al. . Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet 2016;387:1743-52. 10.1016/S0140-6736(16)00215-4 - DOI - PMC - PubMed

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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

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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

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