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Evaluation of an automated feedback intervention to improve antimicrobial prescribing among primary care physicians (OPEN Stewardship): protocol for an interrupted time-series and usability analysis in Ontario, Canada and Southern Israel
  1. Jean-Paul R Soucy1,
  2. Marcelo Low2,
  3. Kamal Raj Acharya3,
  4. Moriah Ellen4,
  5. Anette Hulth5,
  6. Sonja Löfmark5,
  7. Gary E Garber6,7,
  8. William Watson8,9,
  9. Jacob Moran-Gilad10,
  10. David N Fisman1,
  11. Derek R MacFadden11
  1. 1Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  2. 2Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
  3. 3Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
  4. 4Department of Health Services Management, Guilford Glazer Faculty of Business and Management, University of the Negev, Beer Sheva, Israel
  5. 5The Public Health Agency of Sweden, Stockholm, Sweden
  6. 6Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
  7. 7Infectious Diseases, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  8. 8Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
  9. 9St Michael's Hospital, Toronto, Ontario, Canada
  10. 10School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
  11. 11Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  1. Correspondence to Dr Derek R MacFadden; dmacfadden{at}


Introduction Antimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports.

Methods and analysis A non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports.

Ethics and dissemination All sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.

  • infectious diseases
  • public health
  • epidemiology
  • primary care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • DNF and DRM are joint senior authors.

  • Contributors J-PRS, ML, KRA, ME, AH, SL, GEG, WW, JM-G, DNF and DRM conceived the study and the analysis. J-PRS wrote the initial manuscript and will conduct the data analysis. All authors contributed to and approved the final manuscript.

  • Funding This work was supported by the European Commission's Joint Programming Initiative on Antimicrobial Resistance (Swedish Research Council: 2017-05972, Canadian Institutes of Health Research: AMR-155212, Israeli Ministry of Health: 8762491).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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