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Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

BMJ 2013; 347 doi: (Published 26 July 2013) Cite this as: BMJ 2013;347:f4403
  1. Svein Gjelstad, researcher12,
  2. Sigurd Høye, researcher12,
  3. Jørund Straand, professor/head of department1,
  4. Mette Brekke, professor1,
  5. Ingvild Dalen, statistician1,
  6. Morten Lindbæk, professor12
  1. 1Department of General Practice/Family Medicine, Institute of Health and Society, University of Oslo, P O Box 1130, Blindern, N-0318 Oslo, Norway
  2. 2Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo
  1. Correspondence to: S Gjelstad svein.gjelstad{at}
  • Accepted 27 June 2013


Objective To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics.

Design Cluster randomised controlled study.

Setting Existing continuing medical education groups were recruited and randomised to intervention or control.

Participants 79 groups, comprising 382 general practitioners, completed the interventions and data extractions.

Interventions The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner’s antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients.

Main outcome measures Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls.

Results In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm.

Conclusions The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners.

Trial registration Clinical trials NCT00272155.


  • We thank all the peer academic detailers and the members of the participating continuing medical education groups for making this study possible.

  • Contributors: JS, SG, ML, and MB conceived and designed the study and educated the peer academic detailers together with SH. ID, ML, and SG planned the statistical methods. SG collected, modelled, and analysed the data and drafted the manuscript. All authors contributed to interpretation of analyses, critical review or revision, and the final approval of the paper. JS is the guarantor.

  • Funding: The study was carried out with grants from the Norwegian Ministry of Health, the Norwegian Medical Association, and the Research Council of Norway.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; SG is a part time employee of, and has ownership in, the company that produced the computer software for the study.

  • Ethical approval: Approval ID S-05272 from the Regional Ethics Committee South (“REK sør”) was obtained in 2005. The Rx-PAD study was approved by the Regional Committee for Research Ethics and by the Norwegian Social Science Data Services (NSD), which implied acceptance to extract the general practitioners’ prescription data. The Norwegian Directorate for Health and Social Affairs approved exception from health profession secrecy.

  • Data sharing: No additional data available.

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