Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations

Jennifer Shuldiner, Kevin L Schwartz, Bradley J Langford, Noah M Ivers, Ontario Healthcare Implementation Laboratory study team, Monica Taljaard, Jeremy M Grimshaw, Meagan Lacroix, Mina Tadrous, Valerie Leung, Kevin Brown, Andrew M Morris, Gary Garber, Justin Presseau, Kednapa Thavorn, Jerome A Leis, Holly O Witteman, Jamie Brehaut, Nick Daneman, Michael Silverman, Michelle Greiver, Tara Gomes, Michael R Kidd, Jillian J Francis, Merrick Zwarenstein, Jonathan Lam, Cara Mulhall, Sharon Gushue, Sukhleen Uppal, Andrew Wong, Jennifer Shuldiner, Kevin L Schwartz, Bradley J Langford, Noah M Ivers, Ontario Healthcare Implementation Laboratory study team, Monica Taljaard, Jeremy M Grimshaw, Meagan Lacroix, Mina Tadrous, Valerie Leung, Kevin Brown, Andrew M Morris, Gary Garber, Justin Presseau, Kednapa Thavorn, Jerome A Leis, Holly O Witteman, Jamie Brehaut, Nick Daneman, Michael Silverman, Michelle Greiver, Tara Gomes, Michael R Kidd, Jillian J Francis, Merrick Zwarenstein, Jonathan Lam, Cara Mulhall, Sharon Gushue, Sukhleen Uppal, Andrew Wong

Abstract

Background: Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad.

Methods: We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health ("OH Trial"). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario ("PHO Trial"). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization.

Discussion: This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care.

Trial registration: NCT04594200, NCT05044052. CIHR Grant ID: 398514.

Keywords: Antibiotic prescribing; Antimicrobial resistance; Audit and feedback; Process evaluation; Protocol.

Conflict of interest statement

JP is an associate editor of implementation science. JG and NMI are members of the editorial board of implementation science.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Study design of two linked trials
Fig. 2
Fig. 2
Viral prescription pad
Fig. 3
Fig. 3
Emphasis on viral prescription pad inserted in MyPractice: Primary Care report dissemination email
Fig. 4
Fig. 4
Case-mix adjusted comparator and unadjusted comparator
Fig. 5
Fig. 5
Infographic to be included in the emphases on risk harms of antibiotic group
Fig. 6
Fig. 6
Proposed mechanisms of action, informed by the health action process approach [34, 35]
Fig. 7
Fig. 7
Multiple mediation regression models examining the effect of viral prescription pad, prescribing comparator, and harms information [34]

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