Discussion
This study adds to existing evidence (from Italian and international studies8–10) confirming the importance of providing prescribing feedback to physicians during group meetings, specifically supporting AMS programmes, together with information on benefits and risks of antibiotic use in specific clinical circumstances and information on local antimicrobial resistance. Our intervention was particularly aimed at promoting the use of amoxicillin in upper respiratory tract infections, due to its excellent profile in terms of effectiveness and antimicrobial resistance rates. In line with this aim, the quality rather than quantity of prescriptions was affected, as amoxicillin use was significantly higher and amoxiclavulanate use lower in the intervention compared with the control area. This effect occurred early, as it was concentrated during the first year after the intervention and was mostly maintained in the following years. In line with this result, there was an increase in the ratios of prescription rates of amoxicillin/amoxicillin+clavulanate and amoxicillin/other antibiotics in the comparison between the LHA of Reggio Emilia and the rest of the Region.
Since the objective of our study was to assess whether our intervention could improve the quality of paediatricians’ prescribing behaviour, we did not have patient data to assess clinical outcomes associated with antibiotic use. In terms of quantity of antibiotic prescribed, a general reduction in antibiotic prescriptions was observed in both the intervention and control areas. However, Di Mario et al15 showed that such a decrease (that they observed in a period between 2005 and 2019) was not associated with a higher rate of complications in the Emilia-Romagna Region. Anyway, we did not observe any difference between the two areas in the overall prescription of antibiotics, so the increased prescription of amoxicillin in the Reggio Emilia LHA was at the expense of broader spectrum antibiotics (in particular amoxiclavulanate).
The observed effects were consistent with available evidence on the potential effectiveness and relevance of audit and feedback interventions to improve prescribing appropriateness.16 Peer discussion allows for a more in-depth analysis of prescribing dynamics than receiving individual feedback, especially in an educational context where busy physicians can receive evidence-based information from scientific literature and laboratory sources, independent of commercial interests, underlining the relevance for public health of careful use of antibiotics.
The visual comparison of the individual prescriptions of the paediatricians using, for each of them, clusters of histograms which reported each type of antibiotic prescribed together with the number of prescriptions, was a key feature of the prescription reports: everyone could compare their own prescriptions with those of each of their colleagues, so that prescribing variability could be assessed within the health district. This approach was crucial in promoting peer discussion within the meetings and should be particularly considered in small-group meetings with prescribers, as one of the features that can help strengthen the impact of audit and feedback interventions.12 If privacy were of concern, data could be anonymised so that each doctor could simply recognise their own data, keeping the interpeer comparison feature which—once again—is essential to appreciate one’s own prescribing behaviour by looking at variability within the health district, therefore providing more informative feedback.
Discussion of the selected scientific literature was, of course, another key element of our approach: academic detailing has long been shown to be effective in promoting appropriate prescribing through peer discussions, comparing one’s approach with evidence from the available literature.8 17 18 Key features of our intervention included targeted clinician education offering support for clinical decision-making and tailoring messages to the local context,19 also making use of local opinion leaders.
Finally, providing laboratory data on local antibiotic resistance was part of the scientific information provided, to offer better contextualisation on how prescribing is related to resistance and how prescribing less-effective antibiotics may affect the health of individual patients. This is also fundamental in AMS programmes,20 as also highlighted by the WHO.21
The described intervention represents an example of using behavioural science to promote AMS.22 The inappropriate prescription of broad-spectrum antibiotics in epidemiological contexts not requiring the use of β-lactamase inhibitors could be referred as the behavioural diagnosis that requires our intervention; the goal of our AMS strategy was to improve paediatrician prescriptions. The mere availability of guidelines promoting AMS does not in itself lead to changes in prescription practices, and such changes may require additional support through academic detailing. Raising awareness of how one’s prescription habits diverge from these guidelines could be a critical step towards improving prescribing appropriateness. Then, peer comparison within an audit and feedback framework offers fertile ground to discuss possible determinants of prescribing variability and its reasonableness, prompting each peer to analyse their own prescribing habits in light of those of their peers, of scientific evidence and of local resistance data, ultimately shaping ‘social norms’ that drive improvements in prescribing behaviour.23 Evidence supporting behavioural science to address antimicrobial resistance is growing,24 and global and national action plans recommend considering it as part of multifaceted strategies to reduce unnecessary antibiotic prescribing.25 Bearing in mind that AMS strategies should be planned to be long-lasting, as their effects may not be maintained in the long term.26
The intervention was implemented during the district meetings and participation of paediatricians was compulsory. This was a key element to ensure its optimal implementation, together with the careful selection of scientific literature and the prompt availability of prescription reports and local resistance data. However, we are aware that our study has methodological limitations (eg, the retrospective and non-randomised design, the use of administrative data and the possibility that similar interventions could have been conducted in the control area) and cannot bring neither ‘hard’ evidence on change on antibiotic prescribing associated with the multifaceted intervention described, nor evidence on its effects on patient outcomes (which was outside the scope of the study). As baseline data show, our intervention area already had a more favourable prescribing profile than the control area before implementing the intervention. However, the use of a geographically related control area sharing a similar epidemiological context, and statistical adjustments for the baseline data, can strengthen our findings: in both areas, overall prescription of antibiotics in paediatrics had decreased over the study period whereas, in the same period, in the rest of Italy no differences can be appreciated.27 The fact that a favourable impact was observed in a region where attention on the appropriateness of antibiotic prescriptions was already higher than in other Italian contexts may suggest that, if implemented in other regions, our intervention could have an even greater impact.
In conclusion, a multifaceted intervention conducted through small group meetings that promoted peer discussions with the support of scientific data reports that highlight prescribing variability and, speaking of antibiotics, local resistance data, improved prescribing appropriateness of antibiotics at district level. Our study adds to existing evidence on the potential relevance of audit and feedback approaches including academic detailing. The elements of our multifaceted intervention are generally applicable in different outpatient settings and we believe that this type of approach should be considered as part of interventions that should be sustained over time to promote rational prescribing and AMS.