Many GPs who in 2018 received Health Department letters regarding their opioid prescribing criticised the strategy to stem over-prescribing, saying it unfairly targeted doctors who had legitimate reasons to prescribe opioids, such as those working in palliative care.
The appropriateness of these letters is now being looked at by the Australian National Audit Office (ANAO) as part of a wider enquiry into health provider compliance measures.
Jason Soon, a PhD candidate at the Menzies Centre for Health Policy, understands the concerns but says it would be a shame if such poor targeting led to the end of an approach which has shown promise on over- and under-prescribing in a number of settings.
His article is published as part of the TOO MUCH of a Good Thing series, which is investigating how to reduce overdiagnosis and overtreatment in Australia and globally, and is published as a collaboration between Wiser Healthcare and Croakey.
Jason Soon writes:
Audit and feedback is widely used by healthcare service providers to improve professional practice. It involves measuring providers’ performance on clinical and other indicators and then feeding summaries of this performance information back to them.
While it has applications beyond the healthcare sector, audit and feedback is typically undertaken with the aim of inducing clinical behaviour change among healthcare professionals to ensure that they adhere to clinical guidelines and evidence-based practice.
For instance, healthcare professionals may have their performance bench-marked against some measures of wider sector or peer adherence to a specific guideline or evidence-based practice.
This means that audit and feedback can be used to reduce overdiagnosis and overtreatment (e.g. over-prescription of opioids) as well as under-diagnosis and under-treatment (e.g. encouraging the use of spirometry for diagnosis of respiratory conditions).
The value from audit and feedback is not simply because it reminds healthcare professionals about clinical guidelines with which they should already be familiar. Audit and feedback is also aimed at inviting professionals to reflect upon their performance relative to their peers.
The most recent comprehensive review undertaken of the effectiveness of audit and feedback (based on the results of 140 studies) found, among other things, that audit and feedback is more effective when the professionals being targeted are not performing well to start with (so that there is a lot of room for improvement) and when the source of the feedback is a trusted supervisor or colleague.
The same review concluded that the effectiveness of audit and feedback is highly variable and can range from ‘little or no effect to a substantial effect’, with a majority of studies finding an effect clustering around a 4 per cent increase in compliance with desired practice.
More recent studies, which have relied on the use of the audit and feedback to enforce ‘peer pressure’ to improve specifically on poor performers rather than the entire clinician group, have produced less variable results.
For instance, one US trial customised its audit and feedback letters, writing to doctors with the lowest inappropriate prescribing rates for antibiotics (for respiratory infections) via monthly email to tell them they were ‘Top Performers’ while telling the remainder that they were ‘Not a Top Performer’.
These emails also compared the share of inappropriate antibiotic prescriptions written by doctors who were not top performers with the share written by those who were.
High prescribing doctors subjected to this audit and feedback achieved statistically significant reductions of around 16 per cent in inappropriate antibiotic prescribing compared to a control group.
A follow up study found that 12 months after the monthly letters were discontinued, the inappropriate prescribing rate had increased by only 1.5% , meaning that durable improvements were achieved by this approach.
Antibiotics vs opioid prescribing
The Australian Department of Health has also recently targeted audit and feedback initiatives at GPs to reduce rates of inappropriate prescribing of antibiotics.
In 2017, the Department sent letters to GPs whose prescribing rates for antibiotics put them in the top 30 per cent for their practice region. These letters were signed off by the Chief Medical Officer and compared the GP’s prescribing rates with the regional average.
The Department found that the peer comparison letter, when combined with an attention-grabbing graphical representation of the peer comparison, achieved the greatest impact, reducing antibiotic prescription rates by 12.3 per cent over a six-month period.
It even outperformed the same letter when combined with educational materials (but without the graphics).
However, a 2018 trial based on the same peer comparison approach but targeting GPs with high rates of opioid prescribing faced a significant shortcoming.
The Department did not identify (and exclude from targeting) those GPs working in specialist pain settings or with oncology and palliative care patients.
Many GPs who were targeted felt that the letter did not sufficiently account for their patient needs, which required higher rates of opioid prescription.
This promoted a backlash in the medical community which may have reduced the credibility of these comparisons among their target audience.
Similar campaigns based on peer comparison letters are currently underway to target over-prescription of antipsychotic medication and over-use of imaging (paywall). The imaging campaign has already faced similar criticisms (paywall) as the one for opioid prescribing (e.g. not being able to account for special circumstances where the appropriate level of prescription or imaging is higher than average).
In response to these and related complaints, the Australian National Audit Office (ANAO) is now looking at the appropriateness of these letters though as part of a wider enquiry into Department of Health provider compliance measures.
The ANAO report is due out in May 2020 and its findings will be of interest to health policy analysts. While the apparently poor targeting of more recent peer comparison letters highlights one of the implementation challenges of audit and feedback, it would be a shame if it led to the abandonment of an approach which has also demonstrated promise in a number of different settings.
This article is part of an ongoing series that is published as a collaboration between Wiser Healthcare and Croakey.org.
The series investigates how to reduce overdiagnosis and overtreatment in Australia and globally. The articles are also available for republication by public interest organisations, upon request.