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Combined digital and paper audit feedback did not improve asthma prescribing versus digital-only in primary carePaper Letters Add Nothing to Digital Asthma Care Plans

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Key Takeaway
Consider that combined digital and paper audit feedback showed no added benefit over digital-only for asthma prescribing in primary care.

This was a cluster randomized controlled trial conducted in 270 primary care practices in West Yorkshire. Practices were randomized to receive either combined digital and paper audit and feedback reports or digital-only reports on asthma prescribing. The intervention was delivered over seven bimonthly reports.

The primary outcome was the change in the proportion of preventer inhalers prescribed in pressurised metered-dose devices. The result showed no significant difference between the intervention groups. The risk ratio was 1.00 (95% CI 0.98 to 1.03). The absolute change was -0.15% in the intervention group and -0.19% in the control group.

Safety and tolerability were not reported in the abstract. Key limitations included practice mergers in the control group and background trends of mixed improvement following feedback. The certainty note states results are based on a cluster randomized controlled trial, with confidence intervals including no effect.

The practice relevance noted the demonstrated value of an efficient 'real-world' trial embedded within an existing quality improvement initiative. However, the do not overstate guidance clarifies there is no evidence that combined feedback was more effective than digital-only, and background improvements do not imply superiority.

Why paper didn't work better

Many doctors get hundreds of emails every day. They might ignore them or forget to read them. Some thought a physical paper report would grab their attention. This study tested that idea directly.

Doctors often feel overwhelmed by digital messages. They might miss important details in a screen. A printed letter feels more personal and serious.

The team wanted to see if paper helped. They compared two groups of clinics carefully. One group got digital reports only. The other got digital plus paper.

The hidden cost of inhalers

Asthma is a common lung condition affecting many people. It can be hard to control without the right medicine. Some asthma inhalers harm the environment significantly. They release gases that warm the planet over time.

Many doctors prescribe high-carbon inhalers by habit. These devices are easy to use but bad for the air. We need safer options for patients and the planet. Reducing this waste saves money and health.

Doctors want to help their patients breathe better. They also want to protect the environment. But changing habits is not always easy.

What doctors actually saw

They sent reports to 273 clinics in West Yorkshire. Half got digital emails only. Half got emails plus a printed letter. Both groups got feedback seven times over months.

The study ran over a set period in 2026. It tracked which inhalers doctors prescribed carefully. It looked at preventer inhalers specifically to measure change.

Researchers watched how prescribing habits shifted over time. They looked for green alternatives in the data. They wanted to know if paper made a difference.

The surprising shift

The results were clear and simple. There was no difference between the two groups. Doctors did not switch to greener inhalers faster with paper.

Both groups showed some improvement over time. The feedback itself seemed to help them change. But adding paper did not add extra value.

This doesn't mean the feedback was useless.

Experts say changing habits takes a long time. Doctors face many pressures in a busy clinic. Simple reports might not fix deep-rooted routines.

Prescribing is a complex decision for everyone. It involves patient needs and safety first. It also involves environmental concerns for the future. Balancing all three is tough work.

Patients should not worry about this news. Your care plan stays the same for now. Doctors are still working on better options.

The study looked at real-world clinics everywhere. This makes the results strong and true. But it also means many things could change care.

What happens next

Researchers will keep looking for better ways. They want to know what truly motivates doctors. Future studies might test different messages.

More trials are needed to find the right mix. We need to keep lowering carbon emissions. Better tools will come eventually.

Study Details

Study typeRct
EvidenceLevel 2
PublishedApr 2026
View Original 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.
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