Antibiotic overprescribing remains a critical challenge in primary care
Antimicrobial resistance is a growing global public health crisis, with an estimated 1.27 million deaths per year worldwide attributable to drug-resistant infections. The overuse and misuse of antibiotics are significant contributors to this alarming trend. Primary care physicians, who prescribe the majority of antibiotics, play a crucial role in addressing this issue through more judicious antibiotic prescribing.
One promising approach to improving antibiotic stewardship in primary care is the use of audit and feedback interventions. These interventions provide clinicians with data on their prescribing patterns, often in comparison to their peers, with the goal of driving behavior change and reducing unnecessary antibiotic use. However, the optimal design of such audit and feedback interventions remains an area of active research and debate.
A pragmatic trial evaluating different audit and feedback approaches
Researchers in Ontario, Canada, recently conducted a large-scale, pragmatic cluster randomized controlled trial to evaluate the effectiveness of various audit and feedback strategies in reducing antibiotic prescribing among primary care physicians. The study, published in the BMJ, aimed to address several key questions:
- Does providing primary care physicians with feedback on their antibiotic prescribing, compared to their peers, reduce overall antibiotic prescriptions?
- Can further reductions in antibiotic prescribing be achieved by:
a. Providing case-mix adjusted feedback to account for differences in patient populations?
b. Emphasizing the potential harms associated with unnecessary antibiotic use?
The researchers conducted this trial in the province of Ontario, which has a publicly funded healthcare system that provides universal coverage for physician services. All eligible primary care physicians in the province were randomly assigned to one of four groups:
- Control group (no feedback)
- Intervention group with case-mix adjusted feedback and emphasis on antibiotic harms
- Intervention group with case-mix adjusted feedback and no emphasis on antibiotic harms
- Intervention group with unadjusted feedback and emphasis on antibiotic harms
- Intervention group with unadjusted feedback and no emphasis on antibiotic harms
Physicians in the intervention groups received a mailed letter in January 2022 providing them with data on their antibiotic prescribing to patients aged 65 and older, including a comparison to their peers. The researchers then analyzed the impact of these different feedback approaches on several key outcomes, including overall antibiotic prescribing rates, unnecessary antibiotic prescriptions, prolonged-duration prescriptions, and broad-spectrum antibiotic use.
Key findings and implications
The pragmatic trial included a total of 5,046 primary care physicians, with 1,005 in the control group and 4,041 in the intervention groups. The results provide several important insights:
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Peer-comparison feedback significantly reduced overall antibiotic prescribing: At 6 months post-intervention, the mean antibiotic prescribing rate was 59.4 per 1,000 patient visits in the control group, compared to 56.0 per 1,000 patient visits in the intervention group – a 5% relative reduction.
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Unnecessary antibiotic prescriptions and prolonged durations were also reduced: The intervention group saw an 11% relative reduction in unnecessary antibiotic prescriptions and a 15% relative reduction in prescriptions lasting more than 7 days.
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Case-mix adjustment did not provide additional benefits: Providing case-mix adjusted feedback, which accounted for factors like patient age, sex, and comorbidities, did not result in further reductions in antibiotic prescribing. In fact, a small increase in antibiotic prescribing was observed with the case-mix adjusted reports.
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Emphasizing antibiotic harms did not enhance the intervention’s effectiveness: Adding messaging about the potential harms associated with unnecessary antibiotic use did not lead to greater reductions in prescribing compared to the feedback alone.
These findings have several important implications for antibiotic stewardship efforts in primary care:
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Audit and feedback is a scalable and effective intervention: The study demonstrates that a simple, mailed peer-comparison letter can lead to meaningful reductions in unnecessary antibiotic use across a large population of primary care physicians.
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Focusing on appropriate antibiotic durations may be key: The more substantial reductions observed for prolonged-duration prescriptions suggest that targeted messaging on appropriate antibiotic treatment lengths may be a particularly effective strategy.
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Case-mix adjustment and harms messaging may not always enhance effectiveness: The researchers’ attempts to further optimize the audit and feedback intervention through these design modifications did not lead to the expected improvements, highlighting the need for continued research to identify the most impactful intervention components.
Scaling up antibiotic audit and feedback in primary care
The results of this pragmatic trial underscore the potential for antibiotic audit and feedback to be a routine quality improvement initiative in primary care. By providing primary care physicians with transparent, peer-comparison data on their prescribing practices, healthcare systems can empower clinicians to make more judicious antibiotic decisions and contribute to the fight against antimicrobial resistance.
As the ITFix blog highlights, technology-enabled solutions can play a crucial role in scaling up and sustaining these types of audit and feedback interventions. Electronic medical record systems, data analytics platforms, and automated reporting tools can streamline the data collection, analysis, and feedback delivery processes, making it easier for healthcare organizations to implement these interventions at scale.
Moreover, the integration of antibiotic prescribing metrics into existing quality improvement programs, such as Ontario Health’s MyPractice reports, demonstrates how these interventions can be seamlessly incorporated into the workflow of primary care providers. By leveraging existing infrastructure and data sources, healthcare systems can efficiently deliver personalized, actionable feedback to clinicians without adding significant administrative burden.
Conclusion: Antibiotic audit and feedback as a cornerstone of antimicrobial stewardship
The findings from this pragmatic trial in Ontario reinforce the value of antibiotic audit and feedback as a core component of antimicrobial stewardship efforts in primary care. By providing primary care physicians with transparent, peer-comparison data on their prescribing practices, healthcare systems can empower clinicians to make more judicious antibiotic decisions and contribute to the global fight against antimicrobial resistance.
As the healthcare industry continues to explore innovative ways to improve antibiotic stewardship, the lessons learned from this study can inform the design and implementation of similar interventions in primary care settings around the world. By harnessing the power of data-driven feedback and leveraging technology-enabled solutions, we can drive meaningful and sustainable reductions in unnecessary antibiotic use, ultimately improving patient outcomes and safeguarding the future of effective antimicrobial therapies.
