Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial

Abstract

SummaryBackgroundUnnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England.MethodsIn this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed.FindingsBetween Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126·98 (95% CI 125·68–128·27) in the feedback intervention group and 131·25 (130·33–132·16) in the control group, a difference of 4·27 (3·3%; incidence rate ratio [IRR] 0·967 [95% CI 0·957–0·977]; p<0·0001), representing an estimated 73 406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135·00 [95% CI 133·77–136·22] in the patient-focused intervention group and 133·98 [133·06–134·90] in the control group; IRR for difference between groups 1·01, 95% CI 1·00–1·02; p=0·105).InterpretationSocial norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.FundingPublic Health England.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities

“…Maximum benefit may be accrued by focusing attention on the prescribers that are historical outliers. 45 Our data suggest that the high outliers for starting treatment with antibiotics are not the same high outliers for duration or class selection. Therefore, different physician subgroups should be targeted for interventions aimed at each domain of prescribing behaviour.…”

DTB Select: 6 | June 2016

“…The second trial identified 1,581 GP practices throughout England with high overall antibiotic prescribing rates and involved a two-stage process 5. In the first phase, practices were randomised to a control group (no communication) or an intervention group (practices received a letter from England's Chief Medical Officer stating that the practice was prescribing antibiotics at a higher rate than 80% of the practices across the NHS Local Area Team and a patient information leaflet).…”

The General Practitioner Prompt Study to Reduce Cardiovascular and Renal Complications in Patients With Type 2 Diabetes and Renal Complications: Protocol and Baseline Characteristics for a Cluster Randomized Controlled Trial (Preprint)

“…Simple prompts integrated into existing IT systems to identify patients during routine consultation who may not be meeting CV risk factors targets, in combination with education for clinicians may serve as an "aide-mémoire" and provide an opportunity to improve standards of care at low cost 10,11,12 . More specifically, it has been shown to improve adherence to medication in studies targeting a reduction in CVD risk in people with T2DM 13,14 .…”