Effectiveness of audit and feedback in addressing over prescribing of antibiotics and injectable medicines in a middle-income country: an RCT

Abstract

Overprescribing of antibiotics and injectable medicines is common in ambulatory care in many low-and middleincome countries. We evaluated the effects of three different interventions in improving physician prescribing. We conducted a four-armed randomized controlled trial with one-month and three-months follow-up. General physicians, pediatricians, and infectious disease specialists were included in this study if they had an outpatient office in Tehran, Iran. The study involved two behaviorally guided interventions: Bnew-design audit and feedback (NA&F)^; Bprinted educational material (PEM)^and an existing intervention of Broutinely conducted audit and feedback (RA&F)^. The theoretical framework underpinning the intervention was the theory of planned behavior. Main outcome measures were the percentage change in the proportion of prescriptions containing injectable dexamethasone; oral amoxicillin and cefixime. NA&F reduced the proportion of prescriptions particularly those containing dexamethasone injectable and cefixime (1.64, 0.99 absolute percentage change, p = 0.006, p = 0.01 respectively). PEM reduced the proportion of prescriptions containing cefixime (0.93 absolute percentage change p = 0.04). Other primary outcomes had no significant differences. A secondary outcome measure showed overall prescribing of injectables also reduced (absolute risk reduction: 3%). Overally, the study provides strong evidence that using theoretical insights in the development of the intervention improved prescribing behavior that lasted at least three months after the intervention. The design, format, and presentation of messages in feedback forms significantly influence the impact of audit and feedback on physician prescribing. While the interventions were effective, the impacts on inappropriate prescribing were modest and limited. In settings with rampant problems of overprescribing, intensive interventions are required to substantially improve prescribing patterns.

Evaluation of Factors Associated With Appropriate Drug Prescription and Effectiveness of Informative and Educational Interventions—The EDU.RE.DRUG Project

“…In our multifactorial pragmatic and controlled trial, we did not appreciate a decrease in potentially inappropriate prescriptions after 1-year follow-up. Implementing prescription practice with audit and feedback approaches was found to be poorly effective, overall, in primary care ( Soleymani et al, 2019 ; Kroon et al, 2021 ). Nevertheless, our study allowed to identify factors associated with inappropriate prescribing, informing healthcare administrators and policy makers to better design corrective interventions.…”

Antibiotic prescribing in inpatient and outpatient settings in Iran: a systematic review and meta-analysis study

“…In total, 39 (72%) studies were conducted in outpatient settings and 15 (28%) in inpatient settings. Out of 39 studies in outpatient settings, 7 (18%) studies evaluated the effects of interventions on antibiotic prescription [45][46][47][48][49][50][51].…”

“…Since there was difference in the percentage of antibiotic prescribing in before and after of interventions, the results of interventional studies were reported separately from other outpatient studies (Table 2). All the interventions were educational [45][46][47][48][49], and in two studies [50,51], both feedback and educational materials were used. The interventions used in these studies resulted in a relative improvement in antibiotic prescribing pattern; however, in one study, the…”

Effects of restrictive-prescribing stewardship on antibiotic consumption in primary care in China: an interrupted time series analysis, 2012–2017

“…Contrast with our findings, Hersh AL et al [47] found a decline in parenteral antibiotic use after implementing an outpatient parenteral antibiotic therapy (OPAT) stewardship program, which may attribute to the more targeted stewardship specific to parenteral antibiotics. The overuse of injections has become common concerns in many LMICs and may result in unexpected outcomes [48]. However, a wide belief still existed in many cultures that injection is a quite powerful method for health, driving patients preferring injections to oral medicines [49].…”