Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.
Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.
JAMA Intern Med. 2023 Mar 1;183(3):213-220. doi: 10.1001/jamainternmed.2022.6529.
Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population.
To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.
DESIGN, SETTING, AND PARTICIPANTS: This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022.
Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial.
The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups.
A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]).
This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.
ClinicalTrials.gov Identifier: NCT03379194.
抗生素在初级保健中经常被开处方，这增加了人群中对抗微生物药物耐药性的风险。
研究每季度进行审核和反馈对瑞士中高度抗生素处方率的初级保健医生开抗生素处方的影响。
设计、地点和参与者：这项实用随机临床试验于 2018 年 1 月 1 日至 2019 年 12 月 31 日进行，涉及瑞士 3426 名注册的初级保健医生和儿科医生，他们在单一或小型实践中，是抗生素处方量最高的前 75%的医生之一。从 2021 年 9 月 1 日至 2022 年 1 月 31 日，采用协方差分析模型进行意向治疗分析。
初级保健医生以 1:1 的比例随机分为两组，接受每季度进行抗生素处方审核和反馈与同行基准比较，为期 2 年，2017 年作为基线年。使用来自三家为瑞士约 50%参保人提供服务的健康保险公司的匿名患者级索赔数据进行审核和反馈。干预组还收到了呼吸道和尿路感染管理的循证指南和社区抗生素耐药信息。干预组的医生对试验的性质不知情，对照组的医生则未被告知试验情况。
用于审核和反馈的索赔数据用于评估结果。主要结果是第二年每 100 次就诊的抗生素处方率。次要终点包括第一年和两年的总抗生素使用量、喹诺酮类药物和口服头孢菌素的使用情况、所有原因的住院治疗以及 3 个年龄组的抗生素使用情况。
共有 3426 名医生被随机分配到干预组（n=1713）和对照组（n=1713），分别为 629825 名和 622344 名患者提供服务，2017 年基线年共有 4790525 次就诊。在整个队列中，与 2017 年相比，第二年的抗生素处方率相对增加了 4.2%（95%置信区间，3.9%-4.6%）。在干预组中，第二年每 100 次就诊的年度平均抗生素处方率为 8.2（IQR，6.1-11.4），对照组为 8.4（IQR，6.0-11.8）。与整体增长相比，干预组每 100 次就诊的抗生素处方率相对降低了 0.1%（95%置信区间，-1.2%至 1.0%）。与对照组相比，干预组未发现特定抗生素处方率有任何显著降低，除了第二年的喹诺酮类药物（-0.9%[95%置信区间，-1.5%至-0.4%]）。
这项随机临床试验发现，每季度对具有中高度抗生素处方率的初级保健医生进行个性化抗生素处方审核和反馈，以及同行基准比较，并不能降低抗生素处方率。
ClinicalTrials.gov 标识符：NCT03379194。
