Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial

Nick Daneman; Samantha Lee; Heming Bai; Chaim M Bell; Susan E Bronskill; Michael A Campitelli; Gail Dobell; Longdi Fu; Gary Garber; Noah Ivers; Matthew Kumar; Jonathan M C Lam; Bradley Langford; Celia Laur; Andrew M Morris; Cara L Mulhall; Ruxandra Pinto; Farah E Saxena; Kevin L Schwartz; Kevin A Brown

doi:10.1093/ofid/ofac111

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial

Open Forum Infect Dis. 2022 Mar 2;9(5):ofac111. doi: 10.1093/ofid/ofac111. eCollection 2022 May.

Authors

Nick Daneman^{1

2

3

4

5

6}, Samantha Lee³, Heming Bai⁷, Chaim M Bell^{3

4

5

8}, Susan E Bronskill^{3

4

5

9}, Michael A Campitelli³, Gail Dobell⁷, Longdi Fu³, Gary Garber¹⁰, Noah Ivers^{3

4

5

9

11}, Matthew Kumar³, Jonathan M C Lam⁷, Bradley Langford², Celia Laur⁹, Andrew M Morris^{8

12}, Cara L Mulhall⁷, Ruxandra Pinto⁶, Farah E Saxena³, Kevin L Schwartz^{2

3

5}, Kevin A Brown^{2

3}

Affiliations

¹ Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
² Public Health Ontario, Ontario, Canada.
³ ICES, Ontario, Canada.
⁴ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
⁵ Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
⁶ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
⁷ Ontario Health, Ontario, Canada.
⁸ Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada.
⁹ Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
¹⁰ Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
¹¹ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
¹² Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Abstract

Background: Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested 3 behavioral nudging techniques delivered by email to improve report opening.

Methods: We conducted a pragmatic randomized controlled trial among Ontario long-term care prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions.

Results: The trial included 421 physicians caring for >28 000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio [OR], 1.51 [95% confidence interval {CI}, 1.10-2.07], P = .011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR [aOR], 1.74 [95% CI, 1.24-2.45], P = .0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR, 1.62 [95% CI, 1.06-2.47], P = .026; aOR, 2.16 [95% CI, 1.33-3.50], P = .0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR, 1.28 [95% CI, 1.14-1.43], P < .001).

Conclusions: Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.

Clinical trials registration: NCT04187742.

Keywords: antibiotic treatment; drug prescribing; long-term care; nudging; peer comparison audit and feedback.

Associated data

ClinicalTrials.gov/NCT04187742