Audit and Feedback: Effects on Professional Practice and Healthcare Outcomes

Department of Family Medicine, Women’s College Hospital, Toronto, Canada. 2Norwegian Knowledge Centre for the Health Services,Oslo, .
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 06/2012; 6(6):CD000259. DOI: 10.1002/14651858.CD000259.pub3
Source: PubMed


Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.
To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library., including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).
Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.
All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.
We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.
Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

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Available from: Signe Agnes Flottorp, Jan 06, 2015
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    • "Although we are the first to have empirically investigated step 1 in the underlying feedback mechanism, earlier studies aimed at identifying design characteristics and contextual factors that influence the outcome of the mechanism (i.e., change in quality of care). A Cochrane review [1] concluded that low performance scores increased A&F effectiveness. The authors attributed this to greater intention to take action, or absence of ceiling effects [12]; our findings seem to support the first. "
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    ABSTRACT: Audit and feedback (A&F) is widely used to aid healthcare professionals in improving clinical performance, but there is little understanding of the underlying mechanism that determines its effectiveness. The aim of this paper is to investigate the process by which healthcare professionals select indicators as improvement targets based on A&F. We performed a laboratory study among 41 healthcare professionals in the context of a web-based A&F intervention designed to improve the quality of cardiac rehabilitation care in the Netherlands. Feedback was provided on eighteen quality indicators, including a score and a colour (representing a recommendation for selection (red and yellow) or non-selection (green)). Indicators with more room for improvement were more likely to be selected, although this varied substantially between participants. In more than a quarter of the cases, participants did not select indicators with obvious room for improvement (yellow or red colour), or selected indicators without apparent room for improvement (green colour). We conclude that personal preferences and beliefs concerning quality and performance targets may dilute the efficiency of A&F.
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    • "of the RSE programme[17,18]Sportief[15], is also necessary. Activities, such as face-to-face visits, audits and 353 feedback can be an effective way to facilitate the implementation process and to 354 produce higher and more consistent degrees of fidelity212223. On another note, 355 variation in fidelity among organizations can be useful and helpful when 356 professionals share knowledge and experiences at one of the meetings during the "
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