{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T15:18:13Z","timestamp":1776439093951,"version":"3.51.2"},"reference-count":56,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T00:00:00Z","timestamp":1776384000000},"content-version":"unspecified","delay-in-days":16,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["ACF-2020-02-004"],"award-info":[{"award-number":["ACF-2020-02-004"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Institute for Health Research Applied Research Collaboration Yorkshire and Humber","award":["NIHR 200166"],"award-info":[{"award-number":["NIHR 200166"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Resp Res"],"accepted":{"date-parts":[[2026,3,1]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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 \u2018digital and paper\u2019 (intervention) or \u2018digital-only\u2019 (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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u20140.15%; control\u20140.19%; risk ratio\u20141.00; 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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 \u2018green\u2019 alternatives; however, this study demonstrated the value of an efficient \u2018real-world\u2019 trial embedded within an existing quality improvement initiative.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT05761873\">NCT05761873<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjresp-2025-003601","type":"journal-article","created":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T14:30:25Z","timestamp":1776436225000},"page":"e003601","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["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"],"prefix":"10.1136","volume":"13","clinical-trial-number":[{"clinical-trial-number":"nct05761873","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct05761873","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8162-0487","authenticated-orcid":false,"given":"Owen","family":"Thomas","sequence":"first","affiliation":[{"name":"Leeds Institute of Health Science, University of Leeds, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bethan","family":"Copsey","sequence":"additional","affiliation":[{"name":"School of Medicine, University of Leeds, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul","family":"Carder","sequence":"additional","affiliation":[{"name":"West Yorkshire Research and Development Team, West Yorkshire Integrated Care Board, Wakefield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Imran","family":"Mohammed","sequence":"additional","affiliation":[{"name":"West Yorkshire Research and Development Team, West Yorkshire Integrated Care Board, Wakefield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stella","family":"Johnson","sequence":"additional","affiliation":[{"name":"West Yorkshire Research and Development Team, West Yorkshire Integrated Care Board, Wakefield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katherine","family":"Hickman","sequence":"additional","affiliation":[{"name":"Respiratory Lead, West Yorkshire Integrated Care Board, Wakefield, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9686-3067","authenticated-orcid":false,"given":"Toby","family":"Capstick","sequence":"additional","affiliation":[{"name":"Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robbie","family":"Foy","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Science, University of Leeds, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Alderson","sequence":"additional","affiliation":[{"name":"Leeds Institute of Health Science, University of Leeds, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,4,17]]},"reference":[{"key":"2026041707301763000_13.1.e003601.1","doi-asserted-by":"publisher","DOI":"10.1183\/09059180.00001714"},{"key":"2026041707301763000_13.1.e003601.2","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.m4902","article-title":"Air pollution from road traffic contributed to girl\u2019s death from asthma, coroner concludes","volume":"371","author":"Dyer","year":"2020","journal-title":"BMJ"},{"key":"2026041707301763000_13.1.e003601.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(20)30925-9"},{"key":"2026041707301763000_13.1.e003601.4","doi-asserted-by":"publisher","DOI":"10.1183\/20734735.008914"},{"key":"2026041707301763000_13.1.e003601.5","doi-asserted-by":"crossref","unstructured":"Levy M , Andrews R , Buckingham R , et al . 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