Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial

Michael Hallsworth, Tim Chadborn, Anna Sallis, Michael Sanders, Daniel Berry, Felix Greaves, Lara Clements, Sally C Davies, Michael Hallsworth, Tim Chadborn, Anna Sallis, Michael Sanders, Daniel Berry, Felix Greaves, Lara Clements, Sally C Davies

Abstract

Background: Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England.

Methods: In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed.

Findings: Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126.98 (95% CI 125.68-128.27) in the feedback intervention group and 131.25 (130.33-132.16) in the control group, a difference of 4.27 (3.3%; incidence rate ratio [IRR] 0.967 [95% CI 0.957-0.977]; p<0.0001), representing an estimated 73,406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135.00 [95% CI 133.77-136.22] in the patient-focused intervention group and 133.98 [133.06-134.90] in the control group; IRR for difference between groups 1.01, 95% CI 1.00-1.02; p=0.105).

Interpretation: Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.

Funding: Public Health England.

Copyright © 2016 Hallsworth et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1
Figure 1
Trial profile In the first intervention, every general practitioner (GP) in a practice in the intervention group was sent a clinician-focused letter from England's Chief Medical Officer and a leaflet for use with patients (feedback intervention); GPs in the control group received no communication. In the second intervention, every practice manager in practices in the intervention group received patient-focused posters and leaflets (patient-focused intervention); practices in the control group received no communication. NHS=National Health Service.
Figure 2
Figure 2
Rate of antibiotic items dispensed per 1000 weighted population for the feedback intervention, September, 2014, to April, 2015 Error bars represent 95% CIs.
Figure 3
Figure 3
Rate of antibiotic items dispensed per 1000 weighted population for all experimental groups, September, 2014, to April, 2015 Error bars represent 95% CIs.

References

    1. HM Government UK 5 year antimicrobial resistance (AMR) strategy 2013–2018: annual progress report and implementation plan. 2014. (accessed Dec 27, 2015).
    1. WHO Antimicrobial resistance: global report on surveillance. 2014. (accessed Dec 27, 2015).
    1. Davies SC, Fowler T, Watson J. Annual Report of the Chief Medical Officer: infection and the rise of antimicrobial resistance. Lancet. 2013;381:1606–1609.
    1. Harbarth S, Samore MH. Antimicrobial resistance determinants and future control. Emerg Infect Dis. 2005;11:794–801.
    1. Costelloe C, Metcalfe C, Lovering A. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010;340:2096.
    1. Hawker JI, Smith S, Smith GE. Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995–2011: analysis of a large database of primary care consultations. J Antimicrob Chemother. 2014;69:3423–3430.
    1. Public Health England English surveillance programme antimicrobial utilisation and resistance: 2014 report. (accessed Dec 27, 2015).
    1. Ivers N, Jamtvedt G, Flottorp S. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6 CD000259.
    1. Arnold S, Straus S. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;4 CD003539.
    1. Drekonja DM, Filice GA, Greer N. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015;36:142–152.
    1. Ranji SR, Steinman MA, Shojania KG. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care. 2008;46:847–862.
    1. Van der Velden AW, Pijpers EJ, Kuyvenhoven MM. Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections. Br J Gen Pract. 2012;62:801–807.
    1. Tonkin-Crine S, Walker AS, Butler CC. Contributions of behavioural science to antibiotic stewardship: belated recognition of its importance. BMJ. 2015;350:h3413.
    1. John P, Sanders M, Wang J. The use of descriptive norms in public administration: a panacea for improving citizen behaviours? Social Science Research Network. 2014. (accessed Dec 27, 2015).
    1. Health and Social Care Information Centre Prescribing by GP practice. 2013. (accessed Dec 27, 2015).
    1. Pinder R, Sallis A, Berry D. Behaviour change and antibiotic prescribing in healthcare settings: literature review and behavioural analysis. Department of Health and Public Health England. 2015. (accessed Dec 27, 2015).
    1. Huttner B, Goossens H, Verheij T. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10:17–31.
    1. Wang KY, Seed P, Schofield P. Which practices are high antibiotic prescribers? A cross-sectional analysis. Br J Gen Pract. 2009;59:315–320.
    1. Goldstein NJ, Cialdini RB, Griskevicius V. A room with a viewpoint: using social norms to motivate environmental conservation in hotels. J Consum Res. 2008;35:472–482.
    1. Briñol P, Petty RE. Source factors in persuasion: a self-validation approach. Eur Rev Soc Psychol. 2009;20:49–96.
    1. Kazdin A. Behaviour modification in applied settings. 6th edn. Wadsworth; Belmont, CA: 2001.
    1. Lay P. Written communication. In: Baum A, Newman S, Weinman J, editors. Cambridge handbook of psychology, health and medicine. Cambridge University Press; Cambridge: 1997. pp. 331–338.
    1. National Institute for Health and Care Excellence Self-limiting respiratory tract infections – antibiotic prescribing overview. 2015. (accessed Dec 27, 2015).
    1. Public Health England Management of infection guidance for primary care for consultation and local adaption. 2014. (accessed Dec 27, 2015).
    1. Coenen S, Michiels B, Renard D. Antibiotic prescribing for acute cough: the effect of perceived patient demand. Br J Gen Pract. 2006;56:183–190.
    1. Michie S, Richardson M, Johnston M. The Behavior Change Technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46:81–95.
    1. Naughton C, Feely J, Bennett K. An RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing. J Eval Clin Pract. 2009;15:807–812.
    1. Health and Social Care Information Centre Prescriptions dispensed in the community, England 2004–2014. July 7, 2015. (accessed Dec 27, 2015).
    1. NHS Business Services Authority Amendments to the drug tariff April 2015, Part IIIA – professional fees (Pharmacy Contractors) 2015. (accessed Dec 27, 2015).
    1. Arroll B. Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med. 2005;99:255–261.

Source: PubMed

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