Rational use of drugs is an important topic in medicine. Physicians’ prescribing is one of the most frequent medical interventions affecting care outcomes and costs [1], [2], [3]. Several studies have focused on physicians’ prescribing behavior. Audit and feedback have the potential to improve prescribing behavior but studies showed they have little to moderate effect on improving professional practice [3], [4], [5], [6], [7]. According to a Cochrane Review, audit and feedback are defined as providing a summary of the clinical performance of healthcare provider(s) over a specified period of time [6]. Yet, evidence about the feedback effect is inconclusive due to contradictory results [8], [9], [10], [11]. In addition, absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high [4], [8].
Several reports in Iran have shown inappropriate prescribing and usage of corticosteroid drugs in the last decade. Corticosteroid prescribing was reported to have an incidence ranging between ten to fifty percent according to publications from different regions of Iran [5], [12], [13]. It increased nationwide from 12.7% in 1998 to 23% in 2007 [14], based on about 100 million prescriptions [14]. Among steroids, Dexamethasone Phosphate Ampule (8 mg/2 ml) was prescribed in roughly 12% of about 85 million prescriptions in Iranian patients. It has also been placed in the top ten prescribed drugs of any type in Iran over recent years. When not adequately monitored, usage of these drugs may lead to unsafe side effects. Both governmental and other health care organizations are putting much effort in improving the quality of prescriptions.
To ensure the appropriateness of prescription drug use, third party payers widely use retrospective drug utilization reviews [9]. Kerman is the largest province in Iran with around three million people living in its cities and villages. About half of these are covered by insurance via the Kerman Social Security Organization (SSO). More than 1800 general practitioners practice in the province and work together with the SSO. The SSO has a special office called Medical Documents Audit Office (MDAO). In MDAO, the Research and Scientific Council (RSC), run by official staff members, specialists and honorary members, focuses on checking the validity and correctness of diverse medical documents from all medical sections, e.g., medical labs, pharmacies, hospitals, private offices, governmental and private clinics. The main aim of MDAO and RSC is minimizing and preventing prescription drug violations and errors in medical documenting procedures.
MDAO members monitor the practice of physicians continuously. Important data about any individual prescription is recorded in a web based application when dispensed in pharmacy and all data are collected instantly into the comprehensive registry of SSO. In MDAO, the RSC members have weekly meetings for assessing the prescriptions based on reports extracted from the prescription registry. Based on these reports, the RSC director provides feedback letters about many prescribing indices. These letters may include comparison to other providers and advice or appreciation to the recipient. However, the number of weekly letters did not exceed 20, and there was no effort to evaluate their effect. The MDAO hypothesized that systematically sending feedback letters or face to face visits by inviting physicians to MDAO or even going to their offices are effective measures to change physicians' behavior. They hence sought to scientifically evaluate this hypothesis.
In this study we conducted a randomized controlled trial (RCT) aimed to assess whether registry based feedback to general practitioners (GPs) about their professional practice may affect their prescribing of parenteral steroids (PSs). We considered two types of feedback to improve prescribing behavior for PSs: by traditional postal letters (TPLs) and by short text messages (STMs). Also we compared the efficiency of STMs and TPLs. We hypothesized that STM could be a simple, rapid and effective way for providing actionable feedback in the form of quantitative and qualitative indices to the physicians, while respecting privacy and having low cost. The rationale is that these actions would improve their prescribing quality and hence also healthcare outcome.