A systematic review of electronic audit and feedback: intervention effectiveness and use of behaviour change theory

Abstract

BackgroundAudit and feedback is a common intervention for supporting clinical behaviour change. Increasingly, health data are available in electronic format. Yet, little is known regarding if and how electronic audit and feedback (e-A&F) improves quality of care in practice.ObjectiveThe study aimed to assess the effectiveness of e-A&F interventions in a primary care and hospital context and to identify theoretical mechanisms of behaviour change underlying these interventions.MethodsIn August 2016, we searched five electronic databases, including MEDLINE and EMBASE via Ovid, and the Cochrane Central Register of Controlled Trials for published randomised controlled trials. We included studies that evaluated e-A&F interventions, defined as a summary of clinical performance delivered through an interactive computer interface to healthcare providers. Data on feedback characteristics, underlying theoretical domains, effect size and risk of bias were extracted by two independent review authors, who determined the domains within the Theoretical Domains Framework (TDF). We performed a meta-analysis of e-A&F effectiveness, and a narrative analysis of the nature and patterns of TDF domains and potential links with the intervention effect.ResultsWe included seven studies comprising of 81,700 patients being cared for by 329 healthcare professionals/primary care facilities. Given the extremely high heterogeneity of the e-A&F interventions and five studies having a medium or high risk of bias, the average effect was deemed unreliable. Only two studies explicitly used theory to guide intervention design. The most frequent theoretical domains targeted by the e-A&F interventions included ‘knowledge’, ‘social influences’, ‘goals’ and ‘behaviour regulation‘, with each intervention targeting a combination of at least three. None of the interventions addressed the domains ‘social/professional role and identity’ or ‘emotion’. Analyses identified the number of different domains coded in control arm to have the biggest role in heterogeneity in e-A&F effect size.ConclusionsGiven the high heterogeneity of identified studies, the effects of e-A&F were found to be highly variable. Additionally, e-A&F interventions tend to implicitly target only a fraction of known theoretical domains, even after omitting domains presumed not to be linked to e-A&F. Also, little evaluation of comparative effectiveness across trial arms was conducted. Future research should seek to further unpack the theoretical domains essential for effective e-A&F in order to better support strategic individual and team goals.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0590-z) contains supplementary material, which is available to authorized users.

Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care

“…[ 31 – 33 ] A recent systematic review of electronic audit and feedback interventions suggested that insufficient clarity in previous studies meant the active components of interventions could not be fully understood, and recommended that future evaluations of systems should utilise theoretical approaches. [ 34 ] This study specifically aimed to explore the ways in which the intervention was implemented, adopted and embedded into everyday practice (or not) using a qualitative process evaluation consisting of semi-structured interviews with pharmacists, general practitioners, and other general practice staff.…”

Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives

“…The work to date [5][6][7]12] reinforces the role of a bottom-up approach targeting stakeholder engagement, ERAS as the standard approach, the role of education and training, the opportunity to involve patients [14], the importance of audit and feedback [22] visibility of the initiative and the role of nurse coordinators and champions. In order to drive health system transformation we can build upon drivers of High-performance learning systems that engage at the front lines combined with the role of leaders in top-down management strategies that focus on system metrics, process and outcomes.…”

What was visualized? A method for describing content of performance summary displays in feedback interventions

“…Evidence shows that the visual display of performance in feedback interventions can significantly moderate its effects on clinical practice [3,4]. Therefore, important mechanisms of action for A&F may be related to the use of visualizations [5][6][7]. We understand visualizations to include charts, tables, and hybrid displays of graphical elements in tables [8], all of which are commonly used in feedback reports and clinical quality dashboards [9,10].…”