Written ‘report card’ decreases antibiotic prescriptions

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DentistWEBDentists are less likely to prescribe antibiotics after they receive a personalised report detailing their past prescription rates, according to a randomised controlled trial of UK dentists.

The study by Linda Young, NHS Education for Scotland, UK, Jan Clarkson, University of Dundee and Craig Ramsay, Health Services Research Unit, University of Aberdeen, and colleagues.

Dentists prescribe about 10% of the antibiotics dispensed in UK community pharmacies. Previous studies have found that, despite clear clinical guidelines, they often prescribe antibiotics in the absence of clinical need. To test an “audit and feedback” intervention to reduce these inappropriate prescriptions, the RAPiD (Reducing Antibiotic Prescribing in Dentristry) trial relied on dental prescribing and treatment claim data that was already routinely collected by the National Health Service.

The researchers randomly assigned all 795 antibiotic prescribing general dentist practices in Scotland (a total of 2,566 dentists) to either receive or not receive a graph plotting their monthly antibiotic prescribing rate. A random subset of practices in the intervention group also received a written behaviour change message reiterating national recommendations.

At the start of the trial, the total number of antibiotics prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. Over the 12 months following the start of the intervention, dentists in the control group practices prescribed antibiotics at a rate of 7.9 per 100 claims, and dentists in the intervention group practices at a rate of 7.5, representing a 5.7% reduction in antibiotic prescriptions in the intervention group relative to the control group. Furthermore, dentists who received a written behaviour change message had an even greater reduction, of 6.1% relative to intervention dentists who did not receive this message.

While the findings suggest that providing individualised graphical feedback derived from routinely collected data can reduce the antibiotic prescribing rate of dentists, it was not possible to evaluate the impact on the quality or appropriateness of dentists’ antibiotic prescribing in this study.

“The feedback provided in this study is a relatively straightforward, low cost public health and patient safety intervention that could potentially help the entire healthcare profession address the increasing challenge of antimicrobial resistance,” the authors say.

Abstract
Background: Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists’ antibiotic prescribing rates.
Methods and Findings: All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist’s monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists’ prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing.
Conclusions: A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists.

Authors
Paula Elouafkaoui, Linda Young, Rumana Newlands, Eilidh M Duncan, Andrew Elders, Jan E Clarkson, Craig R Ramsay

PLOS material
PLOS Medicine abstract


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