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Changing Clinical Practice: Audit and feedback are of variable effectiveness.
Lead author's name and fax: G Jamtvedt, Department for Research Dissemination and Support, Norwegian Directorate for Health and Social Welfare. grj@shdir.no
Three-part Clinical Question: Is audit and feedback effective in improving professional practice and healthcare outcomes?
Search Terms: In Cochrane Database of Systematic Reviews: change practice.mp (26)
The Review: Study Selection:
Randomised trials of audit and feedback (defined as any summary of clinical
performance over a specified period of time) that reported objectively
measured professional practice in a healthcare setting or healthcare outcomes.
Studies that measured knowledge or performance in a test situation only were
excluded. Data Extraction:
Concealment of allocation, blinding or objective assessment of outcomes,
completeness of follow up. Also: baseline compliance, format of audit and
feedback, frequency of intervention, duration of intervention, content of
feedback, recipient (individual or group). All outcomes were expressed as
non-compliance with desired practice.
The Evidence: 85 studies met the inclusion criteria: 20 trials of preventive care, remainder general management of a variety of problems. One trial in ICU setting. Recipient: 60 trials individuals; 22 trials a group; 3 trials not clear. Format: 46 trails written computer printout; 23 trials verbal; 16 trials both written and verbal. End-point: effect on rate of non-compliance. Effects of audit and feedback varied (effect on rate of non-compliance) between studies: range 9% increase in non-compliance to 71% reduction in non-compliance; median effect 7% reduction in non-compliance (interquartile range 2% reduction to 11% reduction) Effect increased progressively for every 10% increase in rate of baseline non-compliance.
Comments: 1) Do the methods allow accurate testing of the hypothesis? - YES 2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? - YES - Methodologically sound systematic review. 3) Are conclusions valid in light of the results? - YES 4) Did results get omitted, and why? - NO 5) Did they suggest areas of further research? YES - need to focus on standardisation of recording and reporting of baseline rate of clinical practice examined; study intervention; description of participants; and outcomes. Plus consider effects of combined interventions (more than one type) 6) Did they make any recommendations based on the results and were they appropriate? - YES - Effect of audit and feedback generally small to moderate, but this varies. More likely to lead to benefit when baseline compliance with target behaviour is low. When non-compliance more common, more likely to see a beneficial effect. 7) Is the study relevant to my clinical practice? YES - Provision of consistently good healthcare that continuously improves is our aim. We need to know what helps make changes to practice. 8) What level of evidence does this study represent? 1- 9) What grade of recommendation can I make on this result alone? B 10) What grade of recommendation can I make when this study is considered along with other available evidence? No additional evidence to be added. 11) Should I change my practice because of these results? Audit and feedback more likely to be effective in areas of low compliance with targeted behaviour. Limit to these settings when audit is used as a tool to change practice. 12) Should I audit my current practice because of these results? No, use this series of systematic reviews to decide what strategies will help you make changes to your practice. Then audit effects: remember to consider how to accurately record baseline activity.
Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, G4 0SF; 10 November 2003
Email: md23s@udcf.gla.ac.uk
© SICS EBMG 2004 |
