Effectiveness and safety of electronically-delivered prescribing feedback and decision support on antibiotic utilisation for respiratory illness in primary care. REDUCE cluster-randomised trial

Abstract

Objectives: To evaluate the effectiveness and safety at population-scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic (AB) prescribing for self-limiting respiratory infections (RTI).

Design: Open-label, two-arm, cluster randomised controlled trial

Setting: UK general practices in the Clinical Practice Research Datalink

Participants: 79 general practices (582,675 patient-years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care.
Interventions: The AMS intervention comprised a brief training webinar, automated monthly feedback reports of AB prescribing, and electronic decision support tools to inform appropriate AB prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice ‘champion’.

Main outcome measures: The primary outcome was the rate of AB prescriptions for RTI from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Pre-specified sub-group analyses by age-group are reported.

Results: There were 41 AMS trial arm practices (323,155 patient-years) and 38 usual care trial arm practices (259,520 patient-years). AB prescribing rate ratios (RR) were: unadjusted, 0.89 (0.86 to 1.16); and adjusted, 0.88 (95% CI, 0.78 to 0.99, P=0.04); with AB prescribing rates of 98.7 per 1,000 patient-years for AMS (31,907 AB prescriptions) and 107.6 per 1,000 for usual care (27,923 AB prescriptions). AB prescribing was reduced most in adults aged 15-84 years (adjusted RR 0.84, 95%CI 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 (40 to 200) patients. There was no evidence of effect for children less than 15 years (adjusted RR 0.96, 0.82 to 1.12) or adults aged 85 years and older (adjusted RR 0.97, 0.79 to 1.18). There was no evidence that serious bacterial complications increased (adjusted RR 0.92, 0.74 to 1.13).

Conclusions: Electronically-delivered interventions, integrated into practice workflow result in moderate reductions AB prescribing for RTI in adults, which are likely to be of importance for public health. Antibiotic prescribing to children or older people requires further evaluation.

Trial registration: ISRCTN95232781

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Identifiers

ORCID for Paul Little: orcid.org/0000-0003-3664-1873

ORCID for Michael V. Moore: orcid.org/0000-0002-5127-4509

ORCID for Lucy Yardley: orcid.org/0000-0002-3853-883X

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