The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

Bridget K. McCabe, Jeffrey A. Linder, Jason N. Doctor, Mark Friedberg, Craig R. Fox, Noah J. Goldstein, Tara K. Knight, Katrina Kaiser, Jason Tibbels, Steve Haenchen, Stephen D. Persell, Rebecca Warberg, Daniella Meeker*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. Methods: Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1–7% absolute differences in antibiotic prescribing among groups. Discussion: Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use. NCT05138874.

Original languageEnglish (US)
Article number106834
JournalContemporary Clinical Trials
StatePublished - Aug 2022


  • Acute respiratory infection
  • Antibiotic stewardship
  • Antibiotics
  • Telehealth

ASJC Scopus subject areas

  • Pharmacology (medical)


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