Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations.

Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad. We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health ("OH Trial"). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario ("PHO Trial"). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization. This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care. NCT04594200, NCT05044052. CIHR Grant ID: 398514.

Shuldiner J ，Schwartz KL ，Langford BJ ，Ivers NM ，Ontario Healthcare Implementation Laboratory study team ... -  《Implementation Science》

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

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. Pragmatic, factorial randomised controlled trial. 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. 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. 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. 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)). 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. ClinicalTrials.gov NCT04594200.

Schwartz KL ，Shuldiner J ，Langford BJ ，Brown KA ，Schultz SE ，Leung V ，Daneman N ，Tadrous M ，Witteman HO ，Garber G ，Grimshaw JM ，Leis JA ，Presseau J ，Silverman MS ，Taljaard M ，Gomes T ，Lacroix M ，Brehaut J ，Thavorn K ，Gushue S ，Friedman L ，Zwarenstein M ，Ivers N ... -  《BMJ-British Medical Journal》

Process evaluation of two large randomized controlled trials to understand factors influencing family physicians' use of antibiotic audit and feedback reports.

Shuldiner J ，Lacroix M ，Saragosa M ，Reis C ，Schwartz KL ，Gushue S ，Leung V ，Grimshaw J ，Silverman M ，Thavorn K ，Leis JA ，Kidd M ，Daneman N ，Tradous M ，Langford B ，Morris AM ，Lam J ，Garber G ，Brehaut J ，Taljaard M ，Greiver M ，Ivers NM ... -  《Implementation Science》

Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care: A Randomized Clinical Trial.

Aghlmandi S ，Halbeisen FS ，Saccilotto R ，Godet P ，Signorell A ，Sigrist S ，Glinz D ，Moffa G ，Zeller A ，Widmer AF ，Kronenberg A ，Bielicki J ，Bucher HC ... -  《-》

Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP): a study protocol of a cluster randomised trial in dental primary care.

Goulao B ，Scott C ，Black I ，Clarkson J ，McArthur L ，Ramsay C ，Young L ，Duncan E ... -  《Implementation Science》