App-Based Training Module on Guiding Physicians’ Prescription for Antibiotic Treatment of Gonorrhea: Cluster Randomized Controlled Trial

Background: The Chinese National Guidelines on Diagnosis and Treatment of Gonorrhea (2020) recommend ceftriaxone 1 g intramuscularly as a single dose for the treatment of uncomplicated gonococcal infections. However, nonadherence to the guidelines remains common among physicians in China, partly due to their poor awareness of the recommendations. Objective: This trial aimed to (1) assess the effectiveness of an app-based training tool in improving adherence to guideline-recommended treatment regimens and (2) identify reasons for nonadherence among physicians who used the training tool. Methods: Using a cluster randomized controlled trial design, we randomly allocated 72 hospitals (clusters) from 4 provinces to the intervention (n=36, 50%) or control (n=36, 50%) arms in a 1:1 ratio. In the intervention arm, physicians received free app-based training via smartphones for 6 months, while the control arm continued routine training. The primary outcome was the proportion of prescriptions adherent to the regimens for treatment of uncomplicated gonorrhea recommended by the national guidelines. We analyzed cluster-level summary outcomes at endline using methods appropriate for stratified cluster randomized controlled trials with relatively few clusters per group, accounting for between-cluster variation. A postintervention survey was administered to all intervention-arm physicians to evaluate their experience with the app-based training module. Additionally, face-to-face interviews were conducted with 32 purposely selected nonadherent physicians from the intervention arm to explore reasons for nonadherence. Results: A total of 715 physicians (n=343, 48% in the control arm and n=372, 52% in the intervention arm) participated in the study. Over the 6-month intervention period, the adherence to 1 g ceftriaxone for the treatment of uncomplicated gonorrhea increased from 53.6% to 54.8% in the intervention arm, whereas the rate decreased from 43.9% to 42.5% in the control arm. The mean difference (5.5%, 95% CI -7% to 18%; P=.37) in changes in the adherence rate between intervention and control arms was not statistically significant (risk ratio 1.12, 95% CI 0.93-1.35; P=.23). Among the 32 (19%) nonadherent physicians from the intervention arm, the primary reason for nonadherence was their concern regarding the sufficiency of the currently recommended dosage of generic ceftriaxone for treating gonorrhea. Conclusions: In our study, the implementation of an app-based training tool did not improve adherence to treatment recommendations. Concern regarding the efficacy of generic ceftriaxone may be one of the intrinsic factors associated with nonadherence.