Summary of findings
We investigated the impact of variations in the benchmark used for comparison, and in information framing, on the effectiveness of A&F. In accordance with theory and evidence, we hypothesized that greater improvements in practice would be achieved when feedback recipients were compared to the top quartile rather than the median of their peers and when information was risk-framed rather than benefit-framed. There were no significant differences in the monthly mean number of CNS-active medications prescribed per resident over 6 months pre- and post-intervention in any of the four arms, or between arms at 6 months post-intervention. However, engagement with the report amongst those who signed up was poor, such that fewer physicians than anticipated were exposed to the design feature variations. In addition, the mean number of CNS-active medications was relatively low across all arms at baseline (ranging from 1.1 to 1.3), indicating that there was little room for improvement in the primary outcome. As a result, we did not proceed with some of the planned analyses, including the economic evaluation.Importantly, the process evaluation revealed that both factors minimally impacted the proposed underlying mechanisms, which may also help to explain the lack of effects. However, benefit-framed feedback was not perceived as actionable, and physicians described aiming to align their practice with the top quartile, indicating that risk framing and a top quartile comparator still have the potential to achieve change.