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Original Investigation
February 2017

Personalized Prescription Feedback Using Routinely Collected Data to Reduce Antibiotic Use in Primary CareA Randomized Clinical Trial

Author Affiliations
  • 1Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
  • 2Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
  • 3Clinical Trial Unit, University Hospital Basel, University of Basel, Basel, Switzerland
  • 4SASIS AG Solothurn, Switzerland
  • 5Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel, University of Basel, Basel, Switzerland
  • 6Centre for Primary Health Care, University of Basel, University of Basel, Basel, Switzerland
JAMA Intern Med. 2017;177(2):176-183. doi:10.1001/jamainternmed.2016.8040
Key Points

Question  Does quarterly antibiotic prescription feedback to primary care physicians over 2 years reduce antibiotic use when implemented in a complex health care system?

Findings  This nationwide pragmatic randomized trial included 2900 Swiss primary care physicians. Physicians receiving feedback prescribed the same amount of antibiotics to all patients as physicians without feedback. Although physicians receiving feedback prescribed fewer antibiotics to younger patients, this finding was not consistent over the entire intervention period.

Meaning  These findings suggest that quarterly feedback does not change overall antibiotic prescribing. Whether antibiotic use can be reduced in some patient groups remains to be shown.

Abstract

Importance  Feedback interventions using routinely collected health data might reduce antibiotic use nationwide without requiring the substantial resources and structural efforts of other antibiotic stewardship programs.

Objective  To determine if quarterly antibiotic prescription feedback over 2 years reduces antibiotic use when implemented in a complex health care system.

Design, Setting, and Participants  Pragmatic randomized trial using routinely collected claims data on 2900 primary care physicians with the highest antibiotic prescription rates in Switzerland.

Interventions  Physicians were randomized to quarterly updated personalized antibiotic prescription feedback over 2 years (n = 1450) or usual care (n = 1450). Feedback was provided both by mail and online from October 2013 to October 2015 and was supported by an initial 1-time provision of evidence-based guidelines.

Main Outcomes and Measures  The primary outcome was the prescribed defined daily doses (DDD) of any antibiotic to any patient per 100 consultations in the first year analyzed by intention-to-treat. We further analyzed prescriptions of specific antibiotics, age groups, and sex for the first and second year to investigate persistency of effects over time.

Results  The 2900 physicians had 10 660 124 consultations over 2 years of follow-up, prescribed 1 175 780 packages of antibiotics with 10 290 182 DDD. Physicians receiving feedback prescribed the same amount of antibiotics to all patients in the first year (between-group difference, 0.81%; 95% CI, −2.56% to 4.30%; P = .64) and second year (between-group difference, −1.73%; 95% CI, −5.07% to 1.72%; P = .32) compared with the control group. Prescribing to children aged 6 to 18 years was −8.61% lower in the feedback than in the control group in the first year (95% CI, −14.87% to −1.90%; P = .01). This difference diminished in the second year (between-group difference, −4.10%; 95% CI, −10.78% to 3.07%; P = .25). Physicians receiving feedback prescribed fewer antibiotics to adults aged 19 to 65 years in the second year (between-group difference, −4.59%; 95% CI, −7.91% to −1.16%; P < .01). Prescribing to other patient groups or of specific antibiotic types was not significantly different between groups.

Conclusions and Relevance  This nationwide antibiotic stewardship program with routine feedback on antibiotic prescribing was not associated with a change of antibiotic use. In older children, adolescents, and younger adults less antibiotics were prescribed, but not consistently over the entire intervention period.

Trial Registration  clinicaltrials.gov Identifier: NCT01773824

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