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• W4311426949 abstract "Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system. Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system. Antibiotic stewardship strategies can target both prescribers and recipients, with an aim to reduce irrational prescribing.1Zhang Y Yu J Chang J et al.A review of intervention study on rational use of antibiotics based on supply and demand.Chinese Pharmaceutical Affairs. 2018; 32: 15-22Google Scholar, 2Laxminarayan R Van Boeckel T Frost I et al.The Lancet Infectious Diseases Commission on antimicrobial resistance: 6 years later.Lancet Infect Dis. 2020; 20: e51-e60Summary Full Text Full Text PDF PubMed Scopus (118) Google Scholar The most effective strategies usually address the entire range of prescribing drivers arising from emotional, cognitive, and interpersonal aspects.3Donisi V Sibani M Carrara E et al.Emotional, cognitive and social factors of antimicrobial prescribing: can antimicrobial stewardship intervention be effective without addressing psycho-social factors?.J Antimicrob Chemother. 2019; 74: 2844-2847Crossref PubMed Scopus (22) Google Scholar An increasing number of studies have used behavioural science theories to tackle the emotional, cognitive, and interpersonal barriers to reducing antibiotic prescribing.4Tonkin-Crine S Walker AS Butler CC Contribution of behavioural science to antibiotic stewardship.BMJ. 2015; 350h3413Crossref PubMed Scopus (38) Google Scholar These theories have proven to be effective at introducing behavioural changes in various settings,5Fitzpatrick BG Martinez JW Polidan EJ Simulation of social norms interventions in college drinking.Alcohol Clin Exp Res. 2015; 39: 159AGoogle Scholar, 6Higgs S Social norms and their influence on eating behaviours.Appetite. 2015; 86: 38-44Crossref PubMed Scopus (303) Google Scholar and have also been adopted for encouraging desired antibiotic prescribing and consumption behaviours without restricting options.4Tonkin-Crine S Walker AS Butler CC Contribution of behavioural science to antibiotic stewardship.BMJ. 2015; 350h3413Crossref PubMed Scopus (38) Google Scholar, 7Gould IM Lawes T Antibiotic stewardship: prescribing social norms.Lancet. 2016; 387: 1699-1701Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Social norm feedback is one such tool derived from behavioural science theories. Through audit and feedback, an individual's behaviour is compared against a specified goal. In the case of antibiotic stewardship, the goal is usually based on the average antibiotic prescribing rate of peer groups8Ivers N Jamtvedt G Flottorp S et al.Audit and feedback: effects on professional practice and healthcare outcomes.Cochrane Database Syst Rev. 2012; 6CD000259Google Scholar—the so-called social norms. Social norms are defined as the implicit or explicit norms or standards that a group uses to develop values, beliefs, attitudes, or behaviours, which can be used for identifying behavioural outliers.9Reynolds KJ Social norms and how they impact behaviour.Nat Hum Behav. 2019; 3: 14-15Crossref PubMed Scopus (10) Google Scholar The value of social norm feedback is grounded in team processes.10Prentice D Paluck EL Engineering social change using social norms: lessons from the study of collective action.Curr Opin Psychol. 2020; 35: 138-142Crossref PubMed Scopus (33) Google Scholar Because people tend to adjust their behaviour to conform to social norms,11John P Sanders M Wang J A panacea for improving citizen behaviors? Introduction to the symposium on the use of social norms in public administration.J Behav Public Adm. 2019; 2https://doi.org/10.30636/jbpa.22.119Google Scholar social norm feedback can lead to behaviour modifications.12Sheeran P Maki A Montanaro E et al.The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: a meta-analysis.Health Psychol. 2016; 35: 1178-1188Crossref PubMed Scopus (485) Google Scholar Calls are increasing to introduce social norm feedback strategies into antibiotic stewardship to reduce the irrational prescription of antibiotics,4Tonkin-Crine S Walker AS Butler CC Contribution of behavioural science to antibiotic stewardship.BMJ. 2015; 350h3413Crossref PubMed Scopus (38) Google Scholar in particular in primary care.13Steels S Gold N Palin V Chadborn T van Staa TP Improving our understanding and practice of antibiotic prescribing: a study on the use of social norms feedback letters in primary care.Int J Environ Res Public Health. 2021; 18: 1-10Crossref Scopus (4) Google Scholar Peer comparisons are not new to the health sector.14Navathe AS Emanuel EJ Physician peer comparisons as a nonfinancial strategy to improve the value of care.JAMA. 2016; 316: 1759-1760Crossref PubMed Scopus (56) Google Scholar Empirical evidence shows that peer pressure has a considerable effect on the prescribing decisions of medical doctors;15Hall SK Spivak ES How do you stack up? Guideline-based prescribing for acute respiratory illnesses.J Gen Intern Med. 2018; 33: 790Google Scholar, 16Langford BJ Quirk J Carey S Daneman N Garber GE Influencing duration of antibiotic therapy: a behavior change analysis in long-term care.Am J Infect Control. 2019; 47: 1409-1414Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar however, there is a lack of consensus on the effectiveness of social norm feedback in reducing antibiotic prescribing. Social norm feedback can be designed and implemented in various forms, which determine the success of the interventions.8Ivers N Jamtvedt G Flottorp S et al.Audit and feedback: effects on professional practice and healthcare outcomes.Cochrane Database Syst Rev. 2012; 6CD000259Google Scholar, 17Drekonja DM Filice GA Greer N et al.Antimicrobial stewardship in outpatient settings: a systematic review.Infect Control Hosp Epidemiol. 2015; 36: 142-152Crossref PubMed Scopus (173) Google Scholar, 18Soleymani F Rashidian A Hosseini M Dinarvand R Kebriaeezade A Abdollahi M Effectiveness of audit and feedback in addressing over prescribing of antibiotics and injectable medicines in a middle-income country: an RCT.Daru. 2019; 27: 101-109Crossref PubMed Scopus (6) Google Scholar Literature documenting effective social norm feedback designs is sparse.19Szymczak JE Feemster KA Zaoutis TE Gerber JS Pediatrician perceptions of an outpatient antimicrobial stewardship intervention.Infect Control Hosp Epidemiol. 2014; 35: S69-S78Crossref PubMed Scopus (79) Google Scholar, 20Jeffs L McIsaac W Zahradnik M et al.Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: a qualitative study.PLoS One. 2020; 15e0223822Crossref PubMed Scopus (23) Google Scholar This mixed-methods systematic review aims to fill the gap in the literature by investigating whether social norm feedback is an effective strategy for reducing antibiotic prescribing, and identifying the key features of effective social norm feedback designs to reduce antibiotic prescribing. We did a mixed-methods systematic review to qualitatively extract the key behaviour change techniques used in social norm feedback for antibiotic stewardship and quantitatively assess the effectiveness of these techniques in reducing antibiotic prescribing. We followed the Joanna Briggs Institute methodological guidance for the conduct of mixed-methods systematic reviews.21Stern C Lizarondo L Carrier J et al.Methodological guidance for the conduct of mixed methods systematic reviews.JBI Evid Implement. 2021; 19: 120-129Crossref PubMed Scopus (10) Google Scholar Owing to heterogeneity in the social norm feedback designs, subgroup meta-analyses were conducted according to the behaviour change techniques used. This review was registered with PROSPERO (CRD42022361039). Ethical approval of this study was obtained from the Ethics Review Board of the School of Public Health, Sun Yat-sen University, China. We searched PubMed, Embase, Web of Science, and Scopus for relevant studies published between Jan 1, 2000, and Jan 20, 2022, using a combination of search terms relating to social norm feedback and antibiotic prescribing (appendix pp 1–3). The search terms were mapped to those in Medical Subject Headings (PubMed) and Emtree (Embase). Original studies were eligible for inclusion if they were randomised controlled trials (RCTs), non-randomised studies with concurrent controls, or controlled before-and-after studies; reported changes in antibiotic prescriptions or inappropriate antibiotic prescriptions for human use; used professional prescribing norms or peer comparison as an interventional tool with or without other measures; and were published in English. Studies published in other languages and studies reporting antibiotic prescriptions for animals were excluded. Two researchers (YZ and LS) independently screened the titles and abstracts of the identified studies, then assessed the full text of the non-excluded studies against the inclusion and exclusion criteria. In the case of disagreement, a third researcher (LY) was consulted. Consensus was reached among the three researchers for the inclusion of the final studies. A manual search of the references cited by the included studies was conducted to identify additional relevant studies (figure 1). Data were extracted from the included studies into a predefined spreadsheet, which covered five broad areas: the characteristics of study settings and study participants, such as country, year, institution or prescriber targeted, illness condition targeted, and antibiotics prescribed; study design, including the type of trial, frequency and length of interventions, outcome indicators, and statistical analyses; descriptions of behaviour change techniques, such as prompts or nudges, alerts or warnings, and decision support;22Neo JRJ Niederdeppe J Vielemeyer O Lau B Demetres M Sadatsafavi H Evidence-based strategies in using persuasive interventions to optimize antimicrobial use in healthcare: a narrative review.J Med Syst. 2020; 44: 64Crossref PubMed Scopus (6) Google Scholar, 23Garg AX Adhikari NK McDonald H et al.Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.JAMA. 2005; 293: 1223-1238Crossref PubMed Scopus (2325) Google Scholar descriptions of health systems intervention strategies, such as audit and feedback, educational materials, accountability, and commitment;22Neo JRJ Niederdeppe J Vielemeyer O Lau B Demetres M Sadatsafavi H Evidence-based strategies in using persuasive interventions to optimize antimicrobial use in healthcare: a narrative review.J Med Syst. 2020; 44: 64Crossref PubMed Scopus (6) Google Scholar, 23Garg AX Adhikari NK McDonald H et al.Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.JAMA. 2005; 293: 1223-1238Crossref PubMed Scopus (2325) Google Scholar and other details that were deemed relevant to social norm feedback. Two researchers (YZ and LS) independently assessed the risk of bias of the included studies using the Cochrane collaboration risk of bias tool.24Higgins JPT Thomas J Chandler J et al.Cochrane handbook for systematic reviews of interventions version 6.3 (updated February 2022).https://training.cochrane.org/handbookDate accessed: February 20, 2022Google Scholar The percentage of studies with high, low, or unclear risks against each criterion was established by consensus between the two assessors. No studies were excluded because of risk of bias. Instead, we did multiple sensitivity tests by excluding, in turn, all studies with an unclear risk or a high risk on each bias risk aspect. Social norm feedback can be used in many different ways, encompassing a range of intervention measures aimed at health systems improvement. Two researchers (YZ and LS) categorised, with 100% agreement, the social norm feedback design of each study using the health systems intervention taxonomy developed by the Cochrane Effective Practice and Organization of Care (EPOC).25Effective Practice and Organisation of CareEPOC taxonomy.https://epoc.cochrane.org/epoc-taxonomyDate: 2015Date accessed: January 12, 2022Google Scholar The EPOC taxonomy covers four topic lists of health systems interventions, and social norm feedback fits into the category of interventions targeted at health-care workers under the topic list implementation strategies. This category contains 20 subcategories, including audit and feedback, patient-mediated interventions, educational materials, and clinical practice guidelines. When designing social norm feedback studies, the use of interventions falling into more than one subcategory is common. The components of social norm feedback were dissected into what are termed active ingredients, in line with the behaviour change techniques taxonomy.26Michie S Wood CE Johnston M Abraham C Francis JJ Hardeman W Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data).Health Technol Assess. 2015; 19: 1-188Crossref Scopus (306) Google Scholar Active ingredients are the 93 smallest identifiable components that, in themselves, have the potential to change behaviour, which can be restrictive or persuasive, rewarding or punitive27Michie S Richardson M Johnston M et al.The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions.Ann Behav Med. 2013; 46: 81-95Crossref PubMed Scopus (3652) Google Scholar (appendix p 10). The behaviour change techniques coding was done independently by two researchers (YZ and LS). The inter-rater reliability reached 0·994, much higher than the confidence level (≥0·85) required.28Tavakol M Dennick R Making sense of Cronbach's alpha.Int J Med Educ. 2011; 2: 53-55Crossref PubMed Scopus (5723) Google Scholar The two researchers resolved the small number of coding discrepancies through discussion. An example of the behaviour change techniques coding process is shown in the appendix (p 4). The behaviour change technique and EPOC classifications enabled us to conduct subgroup meta-analyses. However, some studies did not contain sufficient detail for reliable classification, and these studies were excluded from subgroup analyses. We used descriptive statistics to summarise the type and number of behaviour change techniques adopted in the included studies. Spearman correlation analysis was done to determine the association between the number of behaviour change techniques and the intervention outcomes. We then calculated the effective ratio (ER) to assess the effect of social norm feedback involving each behaviour change technique. This measure indicates the potential contribution of behaviour change techniques to the effectiveness of the social norm feedback intervention. For example, an ER of 2 indicates that the tested behaviour change technique is used for twice as many effective as ineffective social norm feedback interventions.29Crayton E Richardson M Fuller C et al.Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review.BMC Geriatr. 2020; 20: 237Crossref PubMed Scopus (20) Google Scholar The intervention outcomes were classified as effective, partially effective, and ineffective, consistent with previous studies.30Gardner B Smith L Lorencatto F Hamer M Biddle SJ How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults.Health Psychol Rev. 2016; 10: 89-112Crossref PubMed Scopus (283) Google Scholar, 31Martin J Chater A Lorencatto F Effective behaviour change techniques in the prevention and management of childhood obesity.Int J Obes. 2013; 37: 1287-1294Crossref PubMed Scopus (109) Google Scholar Effective indicates statistical significance of all outcome indicators in pre–post and concurrent control comparisons; partially effective indicates at least one, but not all outcome indicators had statistical significance in pre–post and concurrent control comparisons; and ineffective means that no outcome indicators were statistically significant. The ER is calculated as the total number of effective or partially effective results involving the behaviour change technique divided by the total number of ineffective results involving the technique. The ER could not be calculated if only one study was available. If a specified behaviour change technique intervention showed consistent effective (including partially effective) or ineffective results, the total number of studies reporting the results was presented, rather than the ER. The effect of social norm feedback on reducing antibiotic prescribing outcomes was assessed using meta-analyses, including subgroup analyses stratified by behaviour change techniques. For studies with multiple intervention groups, the group containing the two core elements of social norm feedback (ie, social comparison and feedback on behaviour) but with minimal additional measures was taken for meta-analyses to reduce the risk of overestimating the effect of the social norm feedback intervention. Rate differences (RDs) and 95% CIs were estimated by pre–post comparisons. We used I2 and Q tests to evaluate the heterogeneity of the included studies. Heterogeneity was indicated when I2 was greater than 50% and p was less than 0·05 in Q tests, in which case a random-effect model was adopted to consolidate the RD values; otherwise, a fixed-effect model was applied instead. Stepwise sensitivity analyses were conducted to assess the robustness of the conclusions by excluding studies. The funnel chart method and trim and filling method were used to evaluate publication bias. A consistent result from the trim and filling method indicates small publication bias and a relatively reliable original result.32Duval S Tweedie R Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.Biometrics. 2000; 56: 455-463Crossref PubMed Scopus (8717) Google Scholar 3547 studies were identified, of which 21 met the inclusion criteria. Two more eligible studies were identified through manual searching of reference lists, resulting in a final sample size of 23 studies (figure 1). Almost all included studies were published between 2016 and 2021. The majority were conducted in Europe (n=7) and the USA (n=11). 19 studies had an RCT design, of which six had a quasi-RCT design (appendix pp 11–16). The study outcome indicators were antibiotic prescribing rate18Soleymani F Rashidian A Hosseini M Dinarvand R Kebriaeezade A Abdollahi M Effectiveness of audit and feedback in addressing over prescribing of antibiotics and injectable medicines in a middle-income country: an RCT.Daru. 2019; 27: 101-109Crossref PubMed Scopus (6) Google Scholar, 33Meeker D Linder JA Fox CR et al.Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.JAMA. 2016; 315: 562-570Crossref PubMed Scopus (542) Google Scholar, 34Dutcher L Degnan K Adu-Gyamfi AB et al.Improving outpatient antibiotic prescribing for respiratory tract infections in primary care: a stepped-wedge cluster randomized trial.Clin Infect Dis. 2022; 74: 947-956Crossref PubMed Scopus (4) Google Scholar, 35Chang Y Sangthong R McNeil EB Tang L Chongsuvivatwong V Effect of a computer network-based feedback program on antibiotic prescription rates of primary care physicians: a cluster randomized crossover-controlled trial.J Infect Public Health. 2020; 13: 1297-1303Crossref PubMed Scopus (9) Google Scholar, 36Milani RV Wilt JK Entwisle J Hand J Cazabon P Bohan JG Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports.BMJ Open Qual. 2019; 8e000351Crossref PubMed Scopus (29) Google Scholar, 37Naughton C Feely J Bennett K A RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing.J Eval Clin Pract. 2009; 15: 807-812Crossref PubMed Scopus (31) Google Scholar, 38Daneman N Lee SM Bai H et al.Population-wide peer comparison audit and feedback to reduce antibiotic initiation and duration in long-term care facilities with embedded randomized controlled trial.Clin Infect Dis. 2021; 73: e1296-e1304Crossref PubMed Scopus (7) Google Scholar, 39Cummings PL Alajajian R May LS et al.Utilizing behavioral science to improve antibiotic prescribing in rural urgent care settings.Open Forum Infect Dis. 2020; 7ofaa174Crossref PubMed Scopus (9) Google Scholar, 40Buehrle DJ Shively NR Wagener MM Clancy CJ Decker BK Sustained reductions in overall and unnecessary antibiotic prescribing at primary care clinics in a Veterans Affairs Healthcare System following a multifaceted stewardship intervention.Clin Infect Dis. 2020; 71: e316-e322Crossref PubMed Scopus (21) Google Scholar, 41Johnson MC Hulgan T Cooke RG et al.Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis.BMJ Open Qual. 2021; 10e001275Crossref Scopus (4) Google Scholar, 42Kronman MP Gerber JS Grundmeier RW et al.Reducing antibiotic prescribing in primary care for respiratory illness.Pediatrics. 2020; 146e20200038Crossref PubMed Google Scholar, 43Livorsi DJ Nair R Dysangco A et al.Using audit and feedback to improve antimicrobial prescribing in emergency departments: a multicenter quasi-experimental study in the Veterans Health Administration.Open Forum Infect Dis. 2021; 8ofab186Crossref PubMed Scopus (5) Google Scholar, 44Yadav K Meeker D Mistry RD et al.A multifaceted intervention improves prescribing for acute respiratory infection for adults and children in emergency department and urgent care settings.Acad Emerg Med. 2019; 26: 719-731Crossref PubMed Scopus (44) Google Scholar, 45Persell SD Doctor JN Friedberg MW et al.Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial.BMC Infect Dis. 2016; 16: 373Crossref PubMed Scopus (48) Google Scholar, 46Hallsworth M Chadborn T Sallis A et al.Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial.Lancet. 2016; 387: 1743-1752Summary Full Text Full Text PDF PubMed Scopus (249) Google Scholar, 47Bradley DT Allen SE Quinn H Bradley B Dolan M Social norm feedback reduces primary care antibiotic prescribing in a regression discontinuity study.J Antimicrob Chemother. 2019; 74: 2797-2802Crossref PubMed Scopus (10) Google Scholar, 48Ratajczak M Gold N Hailstone S Chadborn T The effectiveness of repeating a social norm feedback intervention to high prescribers of antibiotics in general practice: a national regression discontinuity design.J Antimicrob Chemother. 2019; 74: 3603-3610Crossref PubMed Scopus (13) Google Scholar, 49Gold N Ratajczak M Sallis A et al.Provision of social-norms feedback to general practices whose antibiotic prescribing is increasing: a national randomized controlled trial.J Public Health. 2022; 30: 2351-2358Crossref Scopus (2) Google Scholar (n=18), total number of antibiotic prescriptions50Schwartz KL Ivers N Langford BJ et al.Effect of antibiotic-prescribing feedback to high-volume primary care physicians on number of antibiotic prescriptions: a randomized clinical trial.JAMA Intern Med. 2021; 181: 1165-1173Crossref PubMed Scopus (15) Google Scholar, 51Elouafkaoui P Young L Newlands R et al.An audit and feedback intervention for reducing antibiotic prescribing in general dental practice: the RAPiD cluster randomised controlled trial.PLoS Med. 2016; 13e1002115Crossref PubMed Scopus (69) Google Scholar, 52Wattal C Goel N Khanna S Byotra SP Laxminarayan R Easton A Impact of informational feedback to clinicians on antibiotic-prescribing rates in a tertiary care hospital in Delhi.Indian J Med Microbiol. 2015; 33: 255-259Crossref PubMed Scopus (9) Google Scholar, 53Hemkens LG Saccilotto R Reyes SL et al.Personalized prescription feedback using routinely collected data to reduce antibiotic use in primary care a randomized clinical trial.JAMA Intern Med. 2017; 177: 176-183Crossref PubMed Scopus (59) Google Scholar (n=4), defined daily dose of prescribed antibiotics52Wattal C Goel N Khanna S Byotra SP Laxminarayan R Easton A Impact of informational feedback to clinicians on antibiotic-prescribing rates in a tertiary care hospital in Delhi.Indian J Med Microbiol. 2015; 33: 255-259Crossref PubMed Scopus (9) Google Scholar, 53Hemkens LG Saccilotto R Reyes SL et al.Personalized prescription feedback using routinely collected data to reduce antibiotic use in primary care a randomized clinical trial.JAMA Intern Med. 2017; 177: 176-183Crossref PubMed Scopus (59) Google Scholar (n=2), and days of treatment54Rosa RM Bushman AM Impact of peer comparison on carbapenem use among inpatient prescribers at a community hospital.Infect Control Hosp Epidemiol. 2020; 41: 376-378Crossref PubMed Scopus (2) Google Scholar (n=1; table 1).Table 1Studies assessing the effect of social normal feedback on antibiotic prescribing behaviourOutcome measureEffectStatistics95% CI or p valueHallsworth et al (2016)46Hallsworth M Chadborn T Sallis A et al.Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial.Lancet. 2016; 387: 1743-1752Summary Full Text Full Text PDF PubMed Scopus (249) Google ScholarAntibiotic items dispensed per 1000 STAR-PUEffective−3·3% relative difference−4·3% to −2·3%Bradley et al (2019)47Bradley DT Allen SE Quinn H Bradley B Dolan M Social norm feedback reduces primary care antibiotic prescribing in a regression discontinuity study.J Antimicrob Chemother. 2019; 74: 2797-2802Crossref PubMed Scopus (10) Google ScholarAntibiotic items dispensed per 1000 STAR-PUEffective−58·7 antibiotic items per 1000 STAR-PU−116·7 to −0·7Ratajczak et al (2019)48Ratajczak M Gold N Hailstone S Chadborn T The effectiveness of repeating a social norm feedback intervention to high prescribers of antibiotics in general practice: a national regression discontinuity design.J Antimicrob Chemother. 2019; 74: 3603-3610Crossref PubMed Scopus (13) Google ScholarAntibiotic items dispensed per 1000 STAR-PUPartially effectiveTotal: RD=−3·69%; top 20% prescribers with an increase in prescribing with (RD=−5·21%) and without (−4·75%) previous feedback letter; top 20% prescribers without an increase in prescribing with (−2·32%) and without (−3·81%) previous feedback letter; top 10% prescribers with (−2·13%) and without (1·47%) previous feedback letter−5·10% to −2·29%; −8·45% to −1·98%; −6·54% to −2·96%; −4·18% to −0·45%; −5·76% to −1·86%; −5·02% to 0·76%; −4·30% to 7·24%Meeker et al (2016)33Meeker D Linder JA Fox CR et al.Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.JAMA. 2016; 315: 562-570Crossref PubMed Scopus (542) Google ScholarInappropriate antibiotic prescribing for acute respiratory tract infectionsEffectiveDifference-in-differences effect=−5·2%−6·9% to −1·6%Schwartz et al (2021)50Schwartz" @default.
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• W4311426949 title "Effects of social norm feedback on antibiotic prescribing and its characteristics in behaviour change techniques: a mixed-methods systematic review" @default.
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