Re: Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
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Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
Re: Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
Dear Editor
Globally, antimicrobial resistance (AMR) poses a major threat to human health. In the U.S., more people die annually from methicillin-resistant Staphylococcus aureus (MRSA) than from several other diseases combined, including emphysema, HIV/AIDS, Parkinson's disease, and murder (1). Antibiotics, which were once considered miraculous, are now less effective due to various factors contributing to antibiotic resistance (2). In Canada, 92% of antibiotic prescriptions are issued for ambulatory settings, indicating a significant proportion of improper antibiotic use (3). So, this study (BMJ 2024;385: e079329) provides valuable insights into the effectiveness of antibiotic audit and feedback in reducing antibiotic prescriptions.
The study explores methods to decrease excessive antibiotic prescriptions in primary care using evidence-based strategies. Drawing on data from over 5000 physicians, the research employs a pragmatic trial design for real-world application. The comprehensive analysis assesses various aspects of antibiotic prescribing practices and utilizes a factorial randomized control design to evaluate the impact of multiple feedback components. This study also highlights the effectiveness of postal feedback in reducing antibiotic prescriptions, underlining its potential for scalable quality improvement in routine primary care settings.
However, I would like to address some of the limitations of this study here also.
First and foremost, Primary healthcare practitioners received mailed letters, but a study found out that sending emails and letters from prominent communicators, such Chief Medical Officers, and clinician-focused letters, can considerably lower the prescribing of antibiotics at a cheap cost and on a national scale (4).Older individuals face complex health scenarios due to comorbidities, drug interactions, and polypharmacy, necessitating careful attention to avoid treatment errors. Although recognizing and addressing polypharmacy is important, practical challenges exist. While providing feedback to doctors via mail is a potential approach, it may not be adequate for addressing individual complex cases. An analysis of the feedback system is crucial to enhance patient safety.
Additionally, peer-comparison feedback, point-of-care diagnostics, and communication skills training have strong supporting data in combating antibiotic resistance. Implementing multiple approaches targeting the general population and prescribers is key to maximizing the impact of community antimicrobial stewardship programs, thereby optimizing antibiotic use and slowing the emergence of antibiotic resistance (5).
1Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety [Internet]. 2014 Oct 16;5(6):229–41. Available from: https://doi.org/10.1177/2042098614554919
2 Mir S, Brett D, De La BA, Martha K. Antibiotics overuse and bacterial resistance. Annals of Microbiology and Research [Internet]. 2019 Oct 26;3(1). Available from: https://doi.org/10.36959/958/573
3 Schwartz KL, Langford BJ, Daneman N, Chen B, Brown KA, McIsaac W, et al. Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data. CMAJ Open [Internet]. 2020 Apr 1;8(2):E360–9. Available from: https://doi.org/10.9778/cmajo.20190175
4 Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet [Internet]. 2016 Apr 1;387(10029):1743–52. Available from: https://doi.org/10.1016/s0140-6736(16)00215-4
5 Schwartz KL, Achonu C, Brown KA, Langford B, Daneman N, Johnstone J, et al. Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study. CMAJ Open [Internet]. 2018 Oct 1;6(4):E445–52. Available from: https://doi.org/10.9778/cmajo.20180017
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Re: Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
Dear Editor
Globally, antimicrobial resistance (AMR) poses a major threat to human health. In the U.S., more people die annually from methicillin-resistant Staphylococcus aureus (MRSA) than from several other diseases combined, including emphysema, HIV/AIDS, Parkinson's disease, and murder (1). Antibiotics, which were once considered miraculous, are now less effective due to various factors contributing to antibiotic resistance (2). In Canada, 92% of antibiotic prescriptions are issued for ambulatory settings, indicating a significant proportion of improper antibiotic use (3). So, this study (BMJ 2024;385: e079329) provides valuable insights into the effectiveness of antibiotic audit and feedback in reducing antibiotic prescriptions.
The study explores methods to decrease excessive antibiotic prescriptions in primary care using evidence-based strategies. Drawing on data from over 5000 physicians, the research employs a pragmatic trial design for real-world application. The comprehensive analysis assesses various aspects of antibiotic prescribing practices and utilizes a factorial randomized control design to evaluate the impact of multiple feedback components. This study also highlights the effectiveness of postal feedback in reducing antibiotic prescriptions, underlining its potential for scalable quality improvement in routine primary care settings.
However, I would like to address some of the limitations of this study here also.
First and foremost, Primary healthcare practitioners received mailed letters, but a study found out that sending emails and letters from prominent communicators, such Chief Medical Officers, and clinician-focused letters, can considerably lower the prescribing of antibiotics at a cheap cost and on a national scale (4).Older individuals face complex health scenarios due to comorbidities, drug interactions, and polypharmacy, necessitating careful attention to avoid treatment errors. Although recognizing and addressing polypharmacy is important, practical challenges exist. While providing feedback to doctors via mail is a potential approach, it may not be adequate for addressing individual complex cases. An analysis of the feedback system is crucial to enhance patient safety.
Additionally, peer-comparison feedback, point-of-care diagnostics, and communication skills training have strong supporting data in combating antibiotic resistance. Implementing multiple approaches targeting the general population and prescribers is key to maximizing the impact of community antimicrobial stewardship programs, thereby optimizing antibiotic use and slowing the emergence of antibiotic resistance (5).
1Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety [Internet]. 2014 Oct 16;5(6):229–41. Available from: https://doi.org/10.1177/2042098614554919
2 Mir S, Brett D, De La BA, Martha K. Antibiotics overuse and bacterial resistance. Annals of Microbiology and Research [Internet]. 2019 Oct 26;3(1). Available from: https://doi.org/10.36959/958/573
3 Schwartz KL, Langford BJ, Daneman N, Chen B, Brown KA, McIsaac W, et al. Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data. CMAJ Open [Internet]. 2020 Apr 1;8(2):E360–9. Available from: https://doi.org/10.9778/cmajo.20190175
4 Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet [Internet]. 2016 Apr 1;387(10029):1743–52. Available from: https://doi.org/10.1016/s0140-6736(16)00215-4
5 Schwartz KL, Achonu C, Brown KA, Langford B, Daneman N, Johnstone J, et al. Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study. CMAJ Open [Internet]. 2018 Oct 1;6(4):E445–52. Available from: https://doi.org/10.9778/cmajo.20180017
Competing interests: No competing interests