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期刊来源：BMJ

原文链接：https://doi.org/10.1136/bmj-2024-079329

摘要内容如下：

目标

评估与同行相比，向家庭医生提供抗生素处方反馈是否会减少抗生素处方。还从病例组合调整反馈报告和强调抗生素相关危害的信息中确定对抗生素处方的影响。

设计

实用、析因随机对照试验。

设置

加拿大安大略省的初级保健医生参与者：所有初级保健医生被随机分配到一个组，如果他们符合条件并积极为65岁或以上的患者开抗生素。如果医生已经自愿接受其他机构的抗生素处方反馈，或者选择退出试验，则被排除在外。

干预

2022年1月向医生邮寄了一封信，与未收到信件的对照组（4:1分配）进行同行比较抗生素处方反馈。干预组在一项2×2析因试验中进一步随机分组，以评估经调整的病例组合与未经调整的对照病例，并强调或不强调抗生素的危害。

主要结果指标

干预后6个月，65岁或以上患者每1000次就诊的抗生素处方率。使用泊松回归对改良意向治疗人群进行分析。

结果

纳入并分析了5046名医生:1005名为对照组，4041名为干预组（1016名为病例组合调整数据和危害信息，1006名为病例组合调整数据和无危害信息，1006名为未调整数据和危害信息，1013名为未调整数据和无危害信息）。6个月时，对照组的平均抗生素处方率为59.4（标准差为42.0），干预组为56.0（标准差为39.2）（相对率为0.95（95%置信区间为0.94至0.96）。与对照组相比，干预组不必要的抗生素处方（0.89（0.86至0.92））、定义为超过7天的延长时间处方（0.85（0.83至0.87））和广谱处方（0.94（0.92至0.95））也显著降低。干预后12个月的结果一致。没有看到强调危害信息的显著效果。根据病例组合调整报告，抗生素处方略有增加（1.01（1.00至1.03））。

结论

同行比较审计和反馈信显著减少了总体抗生素处方，而没有病例组合调整的益处或危害信息。抗生素处方审核和反馈是一种可扩展的有效干预措施，应成为初级保健的常规质量改进举措。

试用注册

ClinicalTrials.gov NCT04594200。

英文原文如下：

Abstracts

OBJECTIVES  To 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.

DESIGN  Pragmatic, factorial randomised controlled trial.

SETTING  Primary care physicians in Ontario, Canada PARTICIPANTS: All 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.

INTERVENTION  A 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 MEASURES  Antibiotic 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.

RESULTS  5046 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)).

CONCLUSIONS  Peer 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 REGISTRATION  ClinicalTrials.gov NCT04594200.

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