Financial strategies targeting healthcare providers to promote the prudent use of antibiotics: a systematic review of the evidence

•Financial strategies were associated with improved antibiotic prescription in the short-term.•Pay-for-performance initiatives were effective in changing prescribing behaviours.•The risk for bias across studies encourages further research to identify causal mechanisms.•Financial strategies can be part of efforts to tackle the emergence and spread of antimicrobial resistance. Improving prudent use of antibiotics is one way to limit the spread of antimicrobial resistance (AMR). The objective of this systematic review was to assess the effects of financial strategies targeting healthcare providers on the prudent use of antibiotics. A systematic review of the literature was conducted searching PubMed, Embase and Cochrane databases, and the grey literature. Search terms related to antibacterial agents, drug resistance, financial strategies, and healthcare providers and/or prescribers. Twenty-two articles were included in the review, reporting on capitation and salary reimbursement, cost containment interventions, pay-for-performance initiatives, penalties, and a one-off bonus payment. There was substantial variation in the reported outcomes describing prescribing behaviours, including proportion of patients prescribed antibiotics, antibiotic prescriptions per patient, and number of cases treated with recommended antibiotic therapy. All financial strategies were associated with improvements in the appropriate prescription of antibiotics in the short-term, although the magnitude of observed effects varied across financial strategies. Financial penalties were associated with the greatest decreases in inappropriate antibiotic prescriptions, followed by capitation models and pay-for-performance schemes that paid bonuses upon achievement of performance targets. However, the risk of bias across studies must be noted. Findings point to the viability of financial strategies to promote the prudent use of antibiotics. Measuring the downstream impact of prescriber behaviour changes is key to estimating the true value of such interventions to tackle AMR. Research efforts should continue to build the evidence on causal mechanisms driving provider prescribing patterns for antibiotics and the long-term impact on antibiotic prescriptions.