Study characteristics
| Authors (year, country) | Setting | Design | Intervention | Justification | Sample size | Outcomes measured | Main findings | Significance |
| Allen et al36 (2019, USA) | Health system (16 community hospitals across 8 counties). | Prospective, pre–post design. | Quarterly peer comparison reports were sent to eligible prescribers (by email, fax or in-person). Eligible prescribers (who accounted for 75%–80% of total prescribed ‘antibiotic days’) were unaware they were high-volume antibiotic prescribers. | Reduce antibiotic prescriptions of fluoroquinolones due to their broad spectrum of activity, known adverse event profile and availability of other less toxic therapeutic options. | Internal medicine; hospitalists; family medicine (n=189). Critical care; pulmonology (n=67). Infectious diseases (n=60). | Primary study outcome was fluoroquinolone days of therapy/1000 patient days (DOT/1000 PD). A day of therapy was defined as at least one dose of a fluoroquinolone in a 24-hour period, per each facility’s medication administration records. | Antibiotic use declined 29% (baseline: 83.9 DOT/1000 PD, range: 59.3–118.7; intervention: 58.3 DOT/1000 PD, range: 37.1–76.7). Primary outcome (fluoroquinolone DOT/1000 PD) declined for all facilities included in the study. | p<0.001 |
| Andereck et al37 (2019, USA) | Large urban academic emergency department (ED). | Prospective pre–post design (quality improvement initiative). | Quarterly feedback by email. Prescribers could compare their rates to peers on a de-identified chart of their peers. Formal education and training complimented the peer intervention (eg, a brief ‘pharmacy fact ’ with each email and a pharmacist lecture). | Unnecessary prescribing patterns have contributed to the opioid epidemic. | Pre-intervention period, 35 636 ED visits were discharged. M=44 attending physicians, 30 senior resident physicians and 33 junior resident physicians and advanced practice providers per block met inclusion. Post-intervention period, a total of 18 830 ED visits were discharged. M=40 attending physicians, 30 senior residents, and 35 junior residents and advanced practice providers per block met inclusion threshold. | The primary outcome of this evaluation was the overall ED discharge opioid prescribing rate. Prescribing rate was defined as the proportion of discharged patient encounters with an opioid prescription for the department in a specific scheduling block. | Departmental opioid prescribing rates during the evaluation period declined; pre-intervention period rate: 8.6% (95% CI: 8.3% to 8.9%) versus post-intervention period rate: 5.8% (95% CI: 5.5% to 6.1%). | p<0.01 |
| Arora et al38 (2019, USA) | Two general medicine inpatient units. | Prospective, cross-sectional pre–post design. | Changing the electronic health record (EHR), creating a default to monitor patient’s vital signs; customised office signs for nurses educating them about best ‘sleep-friendly’ vitals monitoring practices; pocket-cards with information; 20 min education session. | Sleep is important for patient recovery but patients struggle to sleep in hospitals, which is related to poor outcomes. | n=? providers. 1083 general-medicine patients, 1669 EHR general medicine orders. | Changes in the mean percentage of ‘sleep-friendly’ (ie, non-nocturnal) orders for checking vital signs and venous thromboembolism prophylaxis compared with baseline. | Increases in the mean percentage of sleep-friendly orders rose for both: no vital sign: 3% to 22%, sleep-promoting venous thromboembolism prophylaxis: 12% to 28%. | p<0.001 |
| Bourdeaux et al39 (2014, UK) | Inpatient intensive care unit. | Retrospective pre–post design. | Prescription template with preprescribed drugs and fluids doctors choose to use the template on admission. | Chlorhexidine mouthwash reduces ventilator associated pneumonia in critically ill patients. It is cheap and acceptable. Hydroxyethyl starch (HES) is an intravenous fluid that helps circulation. | n=? providers. 2231 ventilated patients were eligible for chlorhexidine, 591 pre-intervention and 1640 post-intervention. 6199 patients were eligible for HES intervention, 2177, pre and 4022 post. | Changes in the delivery of chlorhexidine mouthwash and HES to patients in the intensive care unit. | Percentage of patients prescribed chlorhexidine increased (from 55.3% to 90.4%). The mean volume of HES infused per patient fell and the percentage of patients receiving HES fell (from 54.1% to 3.1%). |
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| Buntinx et al40 (1993, Belgium) | Department of pathology. | Randomised controlled trial (RCT). | Interventions, four groups. Some arms had feedback and then advice. One arm had peer. comparison. | Cervical screening can help prevent cancer. | 183 doctors. | Percentage of smears lacking endocervical cells. | Smears lacking endocervical cells decreased in the groups receiving monthly peer comparison overviews compared with groups not receiving this type of feedback. OR=0.75, 95% CI (0.58 to 0.96). | p<0.05 |
| Chiu et al41 (2018, USA) | Health system (five hospitals). | Prospective pre–post design. | Changing the EHR, lowered the default number of pills on electronic opioid prescriptions from 30 to 12 after procedure. | Postprocedural analgesia prescriptions have contributed to the opioid epidemic. | n=? providers. 1447 procedures before default change and 1463 procedures after the default change. | Changes in the number of opioid pills prescribed per operation. | Decreases in the number of opioid pills prescribed −5.22 (95 CI −6.12 to −4.32). | p<0.01 |
| Delgado et al42 (2018, USA) | Two emergency departments. | Prospective pre–post design. | Changing the EHR, lowered the default number of pills on electronic opioid prescriptions to 10 pills. | Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. | n=? providers. 3264 prescriptions were written across the two EDs. | Increase in 10 pill prescriptions relative to control 4 weeks after implementation; changes in the mean number of oxy/APAP tablets prescribed per week. | Increase in proportion of prescriptions for 10 tablets 27.8%, 95% CI 17.4% to 37.5%. No change in the mean number of oxy/APAP tablets prescribed per week. | p<0.001 |
| Hemkens et al43 (2017, Switzerland) | Nationwide. | Pragmatic RCT. | Personalised antibiotic prescription feedback by mail and an online dashboard and a letter on antibiotic prescribing guidelines. | Clinicians often inappropriately prescribe antibiotics for acute respiratory tract infections. | 2900 primary care physicians. | Changes in defined daily doses of any antibiotic to any patient per 100 consultations in first year, intention-to-treat, relative to control. | No change in prescribing behaviour: between-group difference, 0.81%; 95% CI −2.56% to 4.30%. | N.S. |
| Hempel et al44 (2014, USA) | Emergency department. | Prospective pre–post design. | Peer comparison feedback on emergency medicine resident ultrasound scan numbers. | Clinician-performed ultrasounds are part of emergency medicine residency curricula; there is a need for effective teaching. | 44 emergency medicine residents. | Changes in number of scans done per shift in the 3 months after intervention (relative to baseline). | Increase in number of scans performed (number of ultrasound exams per shift increased from 0.39 scans/shift to 0.61 scans/shift). | p<0.05 |
| Hsiang et al45 (2019, USA) | Health system (25 primary care practices). | Retrospective difference-in-differences approach (intervention vs control practices during post-intervention year compared with the two pre-intervention years). | Active choice of a best-practice alert for medical assistants. During vitals check, the EHR) prompted medical assistants to accept/cancel a cancer screening order. If accepted, a pending order was made for the clinician to review and sign during the patient visit. | US Preventive Services Task Force guidelines for breast and colorectal cancer screening. | n=? providers. 26 269 women eligible for breast cancer screening, 43 647 men eligible for colorectal cancer screening. | Primary outcome was ordering of the screening test during a visit (primary care) compared with control groups relative to two pre-intervention years. | Breast cancer screening tests (22.2% point increase, 95% CI 17.2% to 27.6%) and colorectal cancer screening test increased (13.7% point increase, 95% CI 8% to 18.9%). | p<0.001 |
| Kim et al46 (2018, USA) | 11 primary care practices. | Prospective, cross-sectional pre–post design (differences-in-differences). | Changing the EHR, an ‘active choice’ intervention using a best practice alert directed to medical assistants—prompt to accept or cancel a influenza vaccine order. If accepted, the order was made for the physician to review and sign during the patient visit. | Center for Disease Control recommends universal influenza vaccination. | n=? providers 96, 291 patients. | Changes in influenza vaccination rates compared with control practices over time. | Increase in influenza vaccination rates (9.5% point increase in vaccination rates (95% CI 4.1% to 14.3%). | p<0.001 |
| Kullgren et al47 (2018, USA) | Six adult primary care practices. | 12-month stepped wedge cluster RCT, randomisation by clinic. | Clinicians pre-commited to ‘Choosing Wisely’ choices against low-value orders. They received 1–6 months of point-of-care pre-commitment reminders, patient education handouts and weekly emails. | Clinicians often order costly and inappropriate tests as well as inappropriately prescribe antibiotics for acute respiratory tract infections. | 45 primary care physicians and advanced practice providers. | Primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. | No change in in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis (−1.4%, 95% CI −2.9% to 0.1%). | N.S. |
| Lewis et al48 (2019, UK) | Acute medical hospital. | Controlled interrupted time series design. | Message at the bottom of all inpatient and outpatient paper and electronic CT reports, highlighting patients at risk after exposure to ionising radiation and asks the provider if they informed the patient. | CT scans are known to expose individuals to radiation, which can increase cancer risk. | n=? providers. | Immediate change in level or a gradual trend change in CT counts in electronic reports compared with control hospital. | Significant reduction in CT scans (−4.6%, 95% CI (−7.4% to −1.7%). | p=0.002 |
| Meeker et al49 (2014, USA) | 5 primary care clinics. | RCT, randomisation by clinician. | Poster-sized commitment letters in clinicians’ personal examination rooms for 12 weeks. These letters displayed clinician photographs, signatures and commitment to not inappropriately prescribe antibiotics for acute respiratory infections. | Clinicians often inappropriately prescribe antibiotics for acute respiratory tract infections despite guidelines and several clinical interventions. | 14 clinicians (11 physicians and 3 nurse practitioners) 954 eligible adult patients. | Differences in antibiotic prescribing rates for antibiotic-inappropriate acute respiratory infection diagnoses at baseline and during intervention periods. | Decrease in inappropriate antibiotic prescribing rate compared with control (difference in difference −19.7%, 95% CI (−5.8% to −33.4%). | p<0.05 |
| Meeker et al50 (2016, USA) | 47 primary care practices in two different health systems. | 2×2×2 factorial RCT (practices received 0, 1, 2 or 3 interventions). |
| Clinicians often inappropriately prescribe antibiotics for acute respiratory tract infections. | 248 clinicians (14, 753 visits at baseline and 16, 959 during intervention period). | Changes in rates of inappropriate antibiotic prescribing behaviour compared with baseline. |
| 1. NS; 2. p<0.001; 3. p<0.001. No statistically significant interactions between interventions. |
| Nguyen and Davis51 (2019, USA) | One multispecialty academic medical centre. | Single centre, prospective, quasi-experimental pre–post design. | Peer comparison reports of the percentage of appropriately verified vancomycin orders for each pharmacist. In phase I, reports were blinded. In phase II, reports were unblinded. Intervention phases were compared with a pre-intervention control. | Pharmacist ‘order verification’ prevents medical errors, which are harmful to patients. Vancomycin is a commonly prescribed drug for hospitalised patients. | n=? providers. 1625 vancomycin orders were included for evaluation (537 orders in the control group, 549 orders in intervention phase I and 539 orders in intervention phase II). | Appropriate vancomycin dose order verification, appropriate dose was determined by the institution’s guidelines. | Appropriately verified vancomycin orders significantly increased in the phase II (unblinded) compared with the control group (OR=1.79; 95% CI (1.36 to 2.34). | p<0.001 |
| O’Reilly-Shah et al52 (2018, USA) | Department of anaesthesiology in a large health system (two academic hospitals, two private practice hospitals and two academic surgery centres). | Retrospective pre–post design (stepwise cluster implementation in five facilities). |
| There is a need to improve compliance with anaesthesiology surgical quality metrics. | n=? providers, Total surgical case count (n)=14 793 unique patients (n)=12 785. Five facilities. | Rates of compliance with low tidal wave ventilation compared with baseline. | Attending physician dashboards increased compliance odds 41% (OR 1.41, 95% CI 1.17 to 1.69). Adding advanced practice provider and resident dashboards increased compliance odds 93% (OR 1.93, 95% CI 1.52 to 2.46). Changing ventilator defaults led to 376% increase in compliance odds OR 3.76, 95% CI 3.1 to 4.57. |
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| Olson et al53 (2015, USA) | Clinical pathology, haematology, and oncology departments in a health system. | Prospective pre–post design (multiple baseline). | Changes in the EHR default order sets for post-transfusion haematocrits and platelet counts changed from ‘optional’ to ‘preselected.’ Platelet count default settings later changed back to ‘optional’. | Need to improve the monitoring of post-transfusion outcomes. | >500 residents and fellows. 7578 orders for red blood cell transfusion, 3285 total orders for platelet transfusion. | Rates of laboratory test ordering for post-transfusion counts after default change and post default change. | Increase in haematocrit and platelet post-transfusion count orders after default for order was set to ‘pre-selected’ (8.3% to 57.5% change). After switch back to ‘optional’, significant decrease in orders. | p<0.001 |
| Orloski et al54 (2019, USA) | 2 urban, academic emergency departments. | Prospective, controlled pre–post trial. | Placed institution-branded folding seats in the ED and an educational campaign on good communication. Only the intervention ED received folding seats. | Patient satisfaction is important. | n=? providers. 2827 patients were surveyed. | Primary outcome was the impact of provider sitting on patient satisfaction. Secondary outcome was provider sitting frequency. | Sitting at any point during an ED encounter increased patient satisfaction across all measures (polite: 67% vs 59%, cared: 64% vs 54%, listened: 60% vs 52%, informed: 57% vs 47%, time: 56% vs 45%. Odds of provider sitting increased 30% when a seat was in the room, OR=1.3, 95% CI (1.1 to 1.5). | p<0.0001 |
| Parrino55 (1989, USA) | One tertiary referral hospital. | Prospective pre–post design. | Monthly peer comparison letters sent to two groups (surgical and nonsurgical physicians) who were in the top 50 percentiles of prescribers for antibiotic expenditures. | Antibiotics are often inappropriately prescribed and can be expensive. | 202 physicians, surgical (n=83) and non-surgical (n=119). | Changes in expenditures (total dollars) on antibiotics per physician (mean difference from quarter 3 to quarter 4 compared with control group before and after feedback). | No significant change in total dollars spent on antibiotics (mean difference: $797.50 vs $1355.33). | N.S. |
| Patel et al58 (2014, USA) | One general internal medicine and one family medicine practice. | Retrospective cross-sectional pre–post design. | Modify EHR default from showing brand and generic medications to displaying only generics at first, with the ability to opt out. | Generic medications are less expensive than brand-name medications and are of comparable quality. | Internal medicine (IM) and family medicine (FM) attending physicians (IM, n=38; FM, n=17) and residents (IM, n=166; FM, n=34). | Monthly prescriptions of brand-name and generic equivalent for: beta-blockers, statins and proton-pump inhibitors compared with control. | Increase in generic prescribing behaviour for all three medications; 5.4% points, 95% CI, (2.2% to 8.7%). | p<0.001 |
| Patel et al57 (2016, USA) | Three internal medicine practices. | Prospective cross-sectional pre–post design (difference in differences). | Changing the EHR through ‘active choice’ using a best practice alert for medical assistants and physicians, prompting them to accept/cancel an order for a colonoscopy, mammography or both. Physician needed to review and sign order during visit. | Guidelines suggest that increasing early cancer detection can be done through regular screening practices. | n=? providers, One intervention practice, two controls. 7560 patients eligible for colonoscopy with 14 546 clinic visits and 8337 patients eligible for mammography with 14 410 clinic visits. | Percentage of patients eligible for screening who received a cancer screening order. | Increase in mammography (12.4% points, 95% CI 8.7% to 16.2%) and colonoscopy orders (11.8% points, 95% CI 8% to 15.6%). | p<0.001 |
| Patel et al73 (2016, USA) | All specialties across a health system. | Pre–post design, difference-in-differences approach. | ‘Active choice’ in the EHR. An opt-out ‘checkbox’ that said ‘dispense as written’ was added to the prescription EHR screen, and if unchecked the drug’s generic version was prescribed. | Generic medications are linked to higher adherence to medication regimens and better clinical outcomes. | n=? providers. Pre-intervention data: 811 561 eligible prescription sets during 10-month pre-intervention period to 655 011 prescriptions during 7-month post-intervention period. | Generic prescribing rates for 10 medical conditions, ie, 10 drugs. | The overall generic prescribing rate increased significantly (75.3% to 98.4%). | p<0.001 |
| Patel et al56 (2017, USA) | Three internal medicine practices. | Prospective cross-sectional, pre–post design (difference-in-differences). | Changing the EHR through ‘active choice’ using a best practice alert directed to medical assistants and physicians—prompting to accept/cancel an order for the influenza vaccine. Physician needed to review and sign during the patient visit. | The Center for Disease Control recommends universal influenza vaccination. | n=? providers, One intervention practice, two control practices. 45 926 patients. | Changes in influenza vaccination rates. | Increase in vaccination rates (adjusted difference-in-difference: 6.6% points; 95% CI 5.1% to 8.1%). | p<0.001 |
| Patel et al59 (2018, USA) | One health system, 32 primary care practices (PCPs). | Three-arm cluster randomised clinical trial. |
| 50% of eligible patients do not receive statins despite evidence of their efficacy. | 96 PCPs 4774 patients eligible but not receiving statin therapy. | Percentage of eligible patients receiving statin prescription orders compared with usual care. |
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| Persell et al60 (2016, USA) | General internal medicine clinic. | 2×2×2 factorial RCT with three interventions. |
| Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections. | n=? providers. 3276 visits in the pre-intervention year and 3099 visits in the intervention year. | Rate of oral inappropriate antibiotic prescriptions for acute respiratory infection diagnoses compared with control group and baseline. | No significant decrease in inappropriate prescribing rates compared with control group. Significant decrease in inappropriate prescribing across all groups (including controls) compared with baseline:
| N.S. |
| Ryskina et al61 (2018, USA) | Six general medicine teams in one health system. | Single-blinded cluster RCT, Randomisation by 2 week service. block. | Peer comparison emails sent to physicians on general medicine teams, summarising their routine lab test orders versus the service average that week. | Routine laboratory tests for hospitalised patients can be wasteful and are overused. | Six attending physicians, 114 interns and residents. | Number of routine laboratory orders placed by each physician per patient day. | No significant changes in number of laboratory orders by each physician (−0.14 tests per patient-day vs control group, 95% CI −0.56 to 0.27). | N.S. |
| Sacarny et al20 (2018, USA) | Highest volume primary care prescribers of quetiapine in 2013 and 2014, whose patients have Medicare. | RCT (intent to treat) placebo-control parallel-group design, balanced randomisation (1:1) to control group (placebo letter) and treatment group (peer comparison letter). | Mailed peer comparison letters saying that prescriber’s quetiapine prescribing was under review and was high relative to same-state peers, which was concerning and could be medically unjustified. | Antipsychotic agents like quetiapine fumarate are often overprescribed when not clinically indicated/supported with the potential to cause patient harm. | 5055 PCPs, 231 general practitioners, 2428 were in family medicine, and 2396 were in internal medicine. | Total quetiapine days prescribed by physicians from the intervention start to 9 months in intervention versus control. | Decrease in quetiapine days per prescriber in treatment versus control arm; −11.1%, 95% CI (−13.1% to −9.2%). | p<0.001 |
| Sedrak et al62 (2017, USA) | Three hospitals in one health system. | RCT comparing a 1-year nudge to a 1-year pre-nudge period, accounting for time and patient features. Randomisation at test-level. | Intervention laboratory tests showed Medicare allowable fees at the time of order in the EHR and control laboratory tests did not show prices. | A significant number (30%) of laboratory tests in the USA may be wasteful. Increasing price transparency at the time of laboratory order entry may influence provider decisions and decrease wasteful tests. | n=? providers. 60 diagnostic laboratory tests, 30 most frequently ordered and 30 most expensive. 142, 921 hospital admissions, 98 529 patients. | Frequency of tests ordered per patient-day. Secondary outcome was the number of tests done per patient-day and the Medicare fees. | No significant changes in number of tests ordered between intervention and control group (0.05 tests ordered per patient-day; 95% CI −0.002 to 0.09). | N.S. |
| Sharma et al63 (2019, USA) | One health system, 5 radiation oncology practices. | Stepped-wedge cluster randomised clinical trial. | Change EHR through a default imaging order for no daily imaging during palliative radiotherapy, which physicians could opt-out from by specifying another imaging frequency. | Guidelines suggest that imaging using radiography or CT on a daily basis is unnecessary for patients undergoing palliative radiotherapy. Daily imaging can be costly and increase treatment duration for patients. | 21 radiation oncologists 1019 patients who received 1188 palliative radiotherapy courses (n=747 at university practice; n=441 at community practices) to bone, soft tissue, brain or various sites. | Primary outcome was binary outcome (whether radiotherapy courses with daily imaging were ordered). Daily imaging course was defined as imaging during ≥80% of palliative therapy treatments. | Default led to a significant reduction in daily imaging adjusted OR=0.43; 95% CI 0.24 to 0.77; adjusted difference in % points, −18.6; 95% CI, −34.1 to −2.1. | p=0.004 |
| Shively et al64 (2020, USA) | Veterans' Affairs Health System (seven primary care practices). | Prospective pre–post design. | Peer comparison feedback—an educational session for all primary care providers and monthly emails with their antibiotic prescribing rate, their colleague’s rates and the system’s goal rates. | Clinicians frequently inappropriately prescribe antibiotics despite guidelines. | Baseline=65 primary care professionals (PCPs) serving 40 734 patients, 28 402 office visits. Intervention=73 PCPs serving 41 191 patients, 32 982 office visits. | Monthly mean rate of antibiotic prescribing rates. Secondary outcomes were inappropriate antibiotic prescribing rates and appropriate antibiotic prescribing rates. | Mean rate of monthly antibiotic prescriptions significantly reduced 35.6%. Unnecessary antibiotic prescribing decreased 33.9% and the appropriate antibiotic rates increased 50.8%. | p<0.001 |
| Srinivasan et al65 (2020, USA) | Inpatient units in a 350-bed children’s hospital. | Prospective pre–post design. | EHR reminders, provider education (including a quiz), and peer comparison feedback (how unit rates compared with other units in the hospital, shown on posters and sent by email). | American Academy of Pediatrics guidelines for universal, yearly influenza vaccination for all children 6 months and older. | n=? providers. Baseline=6089 admitted children (6 months and older) to the medical and surgical units. Intervention=6206 children admitted. | Primary outcome was percentage of children discharged with one dose (or greater) of the influenza vaccine (from the hospital or before admission). | Significant increase in the percentage of discharged children with at least 1 dose of the influenza vaccine (4.7-fold increase, from 10% to 46%). | p<0.001 |
| Suffoletto and Landau66 (2019, USA) | Emergency departments in one hospital system, 16 hospitals. | A pilot RCT (randomisation by provider). | Audit and feedback (A&F) emails versus peer norm comparison (PC) emails to other emergency medicine providers at their hospital. | Opioid epidemic is still a persistent problem; need to reduce opioid prescriptions. | 37 emergency medicine providers. | Mean monthly opioid prescriptions by provider. | Opioid prescriptions reduced non-significantly in both conditions (audit and feedback, and peer norm comparison). Mean reduction (SD) was 3.3. (9.6) for controls, 3.9 (10.5) in A&F and 7.3 (7.8) for A&F+PC. | N.S. |
| Szilagyi et al67 (2014, USA) | Practices in two large research networks. | RCT, randomisation unit by practices in two practice-based research networks. | EHR prompts/alerts at all office visits with vaccine recommendations. Reminder sheet on the provider’s desk in the exam room with indicated vaccines. | Guidelines recommend adolescent immunisation for a host of diseases; yet vaccination rates are not in line with guidelines. | n=? providers. Two practice networks: one network: 5 interventions, 5 control practices; one network: 6 interventions, 6 control practices. | Changes in adolescent immunisation rates, by practice. | No significant difference in immunisation rates between intervention and control practices for any vaccine or combination of vaccines (eg, adjusted OR for Human Papillomavirus vaccine at one site: 0.96; 95% CI 0.64 to 1.34), at another: adjusted OR=1.06; 95% CI 0.68 to 1.88. | N.S. |
| Trent et al68 (2018, USA) | One medical centre, an urban, safety net, level one trauma centre. | Stepped wedge design and cluster randomisation. | Monthly audit and feedback emails with blinded peer comparison feedback adherence to guidelines for pneumonia and severe sepsis. Physicians also received emails about patients that got non-adherent service to review. | Adherence to guidelines for pneumonia and sepsis treatment are low in emergency departments. | n=? providers. 469 patients during entire study period. | Primary outcome was guideline-adherent antibiotic choices (guidelines determined by the institution). | Adherence to antibiotic guidelines significantly increased after audit and feedback with peer comparison was introduced (adjusted OR=1.8, 95% CI: 1.01 to 3.2). | p<0.05 |
| Wigder et al69 (1999, USA) | Emergency department in a 600-bed hospital, with a level 1 trauma centre. | Prospective, pre–post design. |
| Physicians over order X-rays when guidelines (ie, the ‘Ottowa rule’) recommend less invasive and cheaper ways for evaluating knee problems/injuries. | 27 physicians. | Primary outcome was changes in patients with knee injuries who received an X-ray study. Secondary outcome was percentage of X-ray orders with abnormal results. | Significant decrease (23%) in number of X-ray studies, increase (58.4%) in percentage of abnormal X-rays compared with baseline. | p<0.001 |
| Winickoff et al70 (1984, USA) | Department of internal medicine at one group practice. | Three interventions: Pre–post design for first two. Third intervention: RCT with crossover design (over a 1 year, crossover at 6 months). |
| Many clinicians do not follow guidelines for colorectal screening. | n=? for first two interventions 16 physicians for RCT (third intervention). | Number of stool tests completed for colorectal cancer screening across groups who received peer comparison intervention. |
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| Zivin et al71 (2019, USA) | Two health systems. | Prospective, pre–post design. | Modify EHR default for all schedule II opioid prescriptions to 15 pills (many EHRs had 30-day defaults previously, others had no default). | The opioid epidemic; overprescription of opioids for postprocedural pain management is a problem and out of step with guidelines. | 448 prescribers. 6390 opioid prescriptions. | Primary outcome was changes in the proportion of opioid prescriptions for 15 pills for high frequency prescribers. | Percentage of 15-pill prescriptions by high prescribers increased from 2.3% to 8.1% (χ2=6.72), 15-pill opioid prescription rates increased at both sites (4.1% to 7.2% at one site, 15.9% to 37.2% at other site). | p<0.04 |
| Zwank et al72 (2017, USA) | Emergency department of a level one trauma centre. | Retrospective pre–post design. | Changing the EHR default number of pills for opioid prescriptions from 15 tablets to a number the physician had to enter themselves. | The opioid epidemic; overdose deaths due to prescriptions from opioids as analgesics. | n=? providers. 7019 eligible prescriptions. | Changes in the total opioid pill quantity per prescription. | No significant change in mean number of opioid tablets per prescription. Mean tablets dispensed increased from 15.31 (SD=5.30) tablets to 15.77 (SD=7.30). | N.S. |