Evidence map›Paper›PMID 38839101›Full record

Trial reportBMJ (Clinical research ed.)2024

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial.

Kevin L Schwartz, Jennifer Shuldiner, Bradley J Langford, Kevin A Brown, Susan E Schultz, Valerie Leung, Nick Daneman, Mina Tadrous, Holly O Witteman, Gary Garber and 13 more

Erratum issued Registry-linked trialAbstract readPragmatic Clinical Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in BMJ (Clinical research ed.), 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. It is linked to trial NCT04594200 (Do Peer-comparisons, Emphasis on Harms, and/or Inclusion of Viral Prescription Pad Resources Increase Responsiveness to Feedback About Antibiotic Prescribing in Primary Care), which is not on this map. Cited by 10 papers, 2 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
10citing papers in PubMed, 2 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT04594200 nacompletednot on this map

Do Peer-comparisons, Emphasis on Harms, and/or Inclusion of Viral Prescription Pad Resources Increase Responsiveness to Feedback About Antibiotic Prescribing in Primary Care (PHO Trial)

TypeinterventionalSponsorWomen's College HospitalRan2022 to 2023Enrolled5,107ConditionsInfectionArmsAudit and Feedback (A&F)
3 · Its place in the literature

Who cites it

10 citing papers in PubMed, 2 syntheses or guidelines pooled it.

  1. Pooled it
  2. Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis.Clinical infectious diseases : an official publication of the Infectious Diseases Society of America · 2025
    Pooled it
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4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

23 authors.

Kevin L SchwartzPublic Health Ontario, Toronto, ON, Canada kevin.schwartz@oahpp.ca.ORCID 0000-0002-3666-7005
Jennifer ShuldinerWomen's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
Bradley J LangfordDalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Kevin A BrownPublic Health Ontario, Toronto, ON, Canada.
Susan E SchultzICES, Toronto, ON, Canada.
Valerie LeungPublic Health Ontario, Toronto, ON, Canada.
Nick DanemanPublic Health Ontario, Toronto, ON, Canada.
Mina TadrousICES, Toronto, ON, Canada.
Holly O WittemanDepartment of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada.
Gary GarberDepartment of Medicine, University of Toronto, Toronto, ON, Canada.
Jeremy M GrimshawDepartment of Medicine, University of Ottawa, Ottawa, ON, Canada.
Jerome A LeisSunnybrook Research Institute, Toronto, ON, Canada.
Justin PresseauClinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Michael S SilvermanWestern University, London, ON, Canada.
Monica TaljaardClinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Tara GomesICES, Toronto, ON, Canada.
Meagan LacroixWomen's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
Jamie BrehautClinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Kednapa ThavornICES, Toronto, ON, Canada.
Sharon GushueOntario Health, Toronto, ON, Canada.
Lindsay FriedmanPublic Health Ontario, Toronto, ON, Canada.
Merrick ZwarensteinDepartments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
Noah IversICES, Toronto, ON, Canada.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectivesTo evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms.

designPragmatic, factorial randomised controlled trial.

settingPrimary care physicians in Ontario, Canada

participantsAll primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial.

interventionA letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics.

main outcome measuresAntibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression.

results5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)).

conclusionsPeer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care.

trial registrationClinicalTrials.gov NCT04594200.

Indexed as

Anti-Bacterial AgentsFeedbackPhysicians, Primary CarePractice Patterns, Physicians'AgedDrug PrescriptionsFemaleHumansMaleOntarioPostal ServiceAnti-Bacterial Agents

Identifiers

PMID38839101
PMCPMC11151833

What OpenQuestion holds

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Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.