Public Health Ontario, Toronto, Ontario, Canada.
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
JAMA Intern Med. 2021 Sep 1;181(9):1165-1173. doi: 10.1001/jamainternmed.2021.2790.
Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance.
To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing.
DESIGN, SETTING, AND PARTICIPANTS: In this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada.
Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis.
The primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis.
Of the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months.
In this randomized clinical trial, a single mailed letter to the highest-prescribing PCPs in Ontario, Canada providing peer-comparison feedback, including messaging on limiting antibiotic-prescribing durations, led to statistically significant reductions in total and prolonged-duration antibiotic prescriptions, as well as drug costs.
ClinicalTrials.gov Identifier: NCT03776383.
抗生素的过度使用会导致药物不良反应、增加成本和抗菌药物耐药性。
评估针对高处方量初级保健医生（PCP）的同行比较审计和反馈，并评估针对避免不必要的抗生素处方和避免长时间处方的针对性信息传递的效果。
设计、地点和参与者：在这项 3 臂随机临床试验中，使用 IQVIA 的 Xponent 数据库中收集的行政数据从加拿大安大略省招募了抗生素处方量最高的四分位数的 PCP（n=3500）。
医生随机分为 3 组，每组 3：3：1，分别接受邮寄的信（2018 年 12 月发出），分别解决抗生素治疗起始（n=1500）和处方持续时间（n=1500）问题，或不接受信件（对照组；n=500）。每个臂的 99 百分位的异常值从分析中排除。
主要结果是干预后 12 个月内抗生素处方的总数。次要结果是长时间处方（>7 天）的数量和抗生素药物费用（加元）。使用稳健泊松回归控制基线处方进行分析。
在纳入分析的 3465 名 PCP 中，2405 名（69.4%）为男性，2116 名（61.1%）距离医学毕业 25 年或以上。在基线时，收到抗生素起始信和持续时间信的 PCP 分别平均开具了 988 和 1000 种抗生素处方；在干预后 12 个月时，这些 PCP 分别平均开具了 849 和 851 种抗生素处方。对于干预后 12 个月的总抗生素处方这一主要结果，与对照组相比，接受起始信的 PCP 的总抗生素使用量没有统计学显著差异（相对风险[RR]，0.96；97.5%置信区间，0.92-1.01；P=0.06），而与对照组相比，持续时间信的差异有统计学意义（RR，0.95；97.5%置信区间，0.91-1.00；P=0.01）。对于接受持续时间信的 PCP，这相当于平均 12 个月内减少 42 次抗生素处方。信组之间没有统计学显著差异。对于起始信，与对照组相比，RR 为 0.98（97.5%置信区间，0.93-1.03；P=0.42）和 0.97（97.5%置信区间，0.92-1.02；P=0.19），分别为长时间处方和抗生素药物成本的结局。在基线时，接受持续时间信的 PCP 平均开具了 332 种长时间处方，药物费用为 14470 加元。相对减少 8.1%（RR，0.92；97.5%置信区间，0.87-0.97；P<0.001）的长时间处方，抗生素药物成本相对减少 6.1%（RR，0.94；97.5%置信区间，0.89-0.99；P=0.01）。这相当于每个 PCP 12 个月内平均减少 24 次长时间处方和 771 加元的药物成本节省。
在这项随机临床试验中，向加拿大安大略省处方量最高的 PCP 发送了一封单独的邮寄信，提供了同行比较反馈，包括关于限制抗生素处方持续时间的信息传递，导致总抗生素处方和长时间处方以及药物成本的统计学显著减少。
ClinicalTrials.gov 标识符：NCT03776383。
