Comparing paper Letters in addition to Emailed Audit and feedback in Refining Asthma treatment to Improve clinical and environmental Results in primary care through a cluster randomised controlled trial: the CLEAR AIR study

Clinical Snapshot

Key Findings

• P Value: Not significant (p-value not provided)

• Effect Size: Intervention group: -0.15% change; Control group: -0.19% change

• Primary Outcome: Proportion of preventer inhalers prescribed as pressurised metered-dose devices

• Nnt Or Sensitivity: Risk ratio 1.00 indicating no treatment effect

• Confidence Interval: 95% CI 0.98 to 1.03

Clinical Application

Digital-only feedback appears as effective as combined digital-paper approach, reducing resource requirements Highly relevant to Australian general practice and Primary Health Networks implementing asthma quality improvement programs. Aligns with RACGP asthma guidelines and potential future carbon reduction initiatives Primary care practices managing patients with asthma, particularly relevant for quality improvement initiatives

Abstract

BACKGROUND: Suboptimal use of preventer inhalers and salbutamol reliever overprescribing are associated with preventable asthma deaths and are a major source of primary care carbon emissions. Audit and feedback produces modest behaviour change by assessing clinical performance and delivering feedback to encourage improvement. Although feedback is increasingly delivered digitally, clinicians may respond more to additional printed feedback reports. We evaluated whether combined digital and paper feedback was more effective than digital-only feedback in promoting safer and greener asthma prescribing at the practice level. METHODS: In this parallel, cluster randomised controlled trial, all 273 primary care practices in West Yorkshire were assigned within their primary care network clusters by stratified, permuted block randomisation to receive seven bimonthly reports on asthma prescribing either in 'digital and paper' (intervention) or 'digital-only' (control) formats. The primary outcome was the proportion of preventer inhalers prescribed in pressurised metred-dose devices due to their high carbon footprint. Intervention group allocation was concealed. The intention-to-treat population was analysed and adjusted for both potential confounders and preintervention achievement. RESULTS: Final analysis assessed 270 practices in 26 clusters per arm due to practice mergers within the control group. There was no significant difference between the intervention groups based on change in the primary outcome (intervention-0.15%; control-0.19%; risk ratio-1.00; 95% CI 0.98 to 1.03) nor any secondary outcome. Analysis of both interventions combined showed a background trend of mixed improvement following feedback. CONCLUSIONS: There was no evidence that combined paper and digital feedback was more effective than digital-only feedback, despite the background of mixed improvements following both interventions. Challenges remain to understanding the barriers to influencing the prescribing of preventer inhalers and transitioning inhaler devices towards low-carbon 'green' alternatives; however, this study demonstrated the value of an efficient 'real-world' trial embedded within an existing quality improvement initiative. TRIAL REGISTRATION NUMBER: NCT05761873.

References

1. 1.Thomas, O., Copsey, B., Carder, P., Mohammed, I., Johnson, S., Hickman, K., Capstick, T., Foy, R., & Alderson, S. (2026). Comparing paper Letters in addition to Emailed Audit and feedback in Refining Asthma treatment to Improve clinical and environmental Results in primary care through a cluster randomised controlled trial: the CLEAR AIR study. BMJ Open Respiratory Research, Article 003601. https://doi.org/10.1136/bmjresp-2025-003601