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Behavioral nudges to improve audit and feedback report opening among antibiotic prescribers: a randomized controlled trial

Daneman N, Lee S, Bai H, Bell CM, Bronskill SE, Campitelli MA, Dobell G, Fu L, Garber G, Ivers N, Kumar M, Lam JMC, Langford B, Laur C, Morris AM, Mulhall CL, Pinto R, Saxena FE, Schwartz KL, Brown KA. Open Forum Infect Dis. 2022; 9(5):ofac111. Epub 2022 Mar 2. DOI: https://doi.org/10.1093/ofid/ofac111


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 three behavioral nudging techniques delivered by email to improve report opening.

Methods — We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) 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 more than 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%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). 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=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p<0.001).

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

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