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Effect of Antibiotic-Prescribing Feedback to High-Volume Primary Care Physicians on Number of Antibiotic PrescriptionsA Randomized Clinical Trial

Educational Objective
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.
1 Credit CME
Key Points

Question  Does providing a single, mailed, peer-comparison letter on antibiotic use to high-prescribing primary care physicians targeting either initiation or duration of antibiotic treatment modify prescribing behavior?

Findings  In this randomized clinical trial of 3500 primary care physicians in Ontario, Canada, receipt of a letter targeting appropriate antibiotic durations resulted in a statistically significant 4.8% relative reduction in total antibiotic use.

Meaning  A single, peer-comparison, antibiotic-feedback letter to high-prescribing physicians can be effective and cost saving, especially if it includes targeted messaging on appropriate durations of antibiotic prescriptions.


Importance  Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance.

Objective  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.

Interventions  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.

Main Outcomes and Measures  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.

Results  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.

Conclusions and Relevance  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.

Trial Registration  ClinicalTrials.gov Identifier: NCT03776383

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: April 27, 2021.

Published Online: July 6, 2021. doi:10.1001/jamainternmed.2021.2790

Corresponding Author: Kevin L. Schwartz, MD, Public Health Ontario, 480 University Ave, Ste 300, Toronto, ON M5G 1V2, Canada (kevin.schwartz@oahpp.ca).

Author Contributions: Mr Neish had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schwartz, Ivers, Langford, Taljaard, Daneman, Alloo, Silverman, Grimshaw, Wu, Garber.

Acquisition, analysis, or interpretation of data: Schwartz, Ivers, Langford, Taljaard, Neish, Brown, Leung, Daneman, Alloo, Shing, Grimshaw, Leis.

Drafting of the manuscript: Schwartz, Neish, Silverman.

Critical revision of the manuscript for important intellectual content: Ivers, Langford, Taljaard, Brown, Leung, Daneman, Alloo, Silverman, Shing, Grimshaw, Leis, Wu, Garber.

Statistical analysis: Taljaard, Neish, Brown, Shing.

Obtained funding: Schwartz.

Administrative, technical, or material support: Schwartz, Langford, Leung, Leis, Wu, Garber.

Supervision: Taljaard, Silverman, Garber.

Other—partnership development and implementation support: Alloo.

Conflict of Interest Disclosures: Dr Ivers reported support from a Canada Research Chair (Tier 2) in Implementation of Evidence-Based Practice and a Clinician Scholar award from the Department of Family and Community Medicine at the University of Toronto, as well as grants from the Canadian Institutes of Health Research and the Joint Programming Initiative on Antimicrobial Resistance outside the submitted work. Dr Alloo reported grants from the University of Toronto and personal fees from Novo Nordisk, Roche, Eli Lilly, AstraZeneca, Memotext, the Centre for Addiction and Mental Health, Trillium Health Partners, Ontario College of Family Physicians, and the Section on General and Family Practice at Ontario Medical Association outside the submitted work. Dr Leis reported personal fees from Choosing Wisely Canada during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by Public Health Ontario and a Canadian Institutes of Health Research Strategy for Patient-Oriented Research Innovative Clinical Trials grant (application No. 398514).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The lead author, Dr Schwartz, affirms that this article is an honest, accurate, and transparent account of the study being reported. No important aspects have been omitted, and any discrepancies from the original protocol have been explained.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank our lived-experience patient partners Emily Angl, BMSc, and Barbara Sklar, RN, BAEd/ADED, for their contributions to this study. Ms Angl received compensation through the study funding for her time consulting on this article.

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