Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial



Antibiotics prescribed for acute respiratory tract infections in the telemedicine setting are often unwarranted.


We hypothesized that education plus individualized feedback, compared with education alone, would significantly reduce antibiotic prescription rates for upper respiratory infections, bronchitis, sinusitis, and pharyngitis in a telemedicine setting.


Two-arm, parallel-group randomized controlled trial conducted at a telemedicine practice from January 1, 2018, to November 30, 2018.


Clinicians employed at the practice on or after January 1, 2017 (n = 45).


The control group received education (treatment guideline presentation and online course) in April 2018. The intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide antibiotic prescription rates starting May 2018.

Main Measures

Antibiotic prescription for any visit with at least one target condition: upper respiratory tract infection, bronchitis, sinusitis, and pharyngitis.

Key Results

Baseline antibiotic prescription rates in control and intervention groups across conditions were as follows: upper respiratory infection (URI): 626/3410 (18.4%), 413/2752 (15.0%), bronchitis: 689/1471 (46.8%), 742/1162 (64.0%), sinusitis: 5154/6131 (84.1%), 4250/4876 (87.2%), pharyngitis: 2308/2838 (81.3%), 1593/2126 (74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period, for both control and intervention groups. Reduction of antibiotic prescriptions for URI and bronchitis was greater for the group receiving education plus individualized feedback compared with that for the group receiving education alone (interaction term ratio 0.60, 95% CI 0.47 to 0.77 for URI; and interaction term ratio 0.42, 95% CI 0.32 to 0.55 for bronchitis), but not sinusitis and pharyngitis.


Education plus individualized feedback in a telemedicine practice significantly decreased antibiotic prescription rates for upper respiratory tract infections and bronchitis, compared with education alone. Future studies should focus on tailoring antibiotic stewardship programs based on underlying conditions, and the maintenance of early reductions in antibiotic prescription.

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Corresponding author

Correspondence to Rana F. Hamdy MD.

Ethics declarations

This study was considered exempt by the George Washington Institutional Review Board. Consent was obtained from all clinicians enrolled in the study and informed consent from patients was waived given the use of de-identified data.

Conflict of Interest

Lily Yan was an intern at Doctor On Demand from January to April 2016. The following authors are employed at Doctor On Demand: Kristin Dean as Associate Medical Director, James Thompson as Vice President of Business Intelligence and Data Analytics, and Ian Tong as Chief Medical Officer.

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Prior presentations: IDWeek in San Francisco, CA on Oct 4 2018. Annual International Pediatric Antimicrobial Stewardship Conference in St. Louis, MO, on May 31, 2019.

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Du Yan, L., Dean, K., Park, D. et al. Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial. J GEN INTERN MED 36, 305–312 (2021).

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  • antibiotic stewardship
  • telemedicine
  • acute respiratory tract infections
  • inappropriate prescribing