Audit and feedback: effects on professional practice and healthcare outcomes

Effects of Repeated Feedback on Pain Documentation: A Cluster Randomized Trial

PURPOSE

The study aimed to determine how pain documentation audits and repeated feedback (REFPAD intervention) affect registered nurses' pain documentation and knowledge, and to discover how background variables relate to such documentation and knowledge.

DESIGN

A cluster randomized trial.

METHODS

Thirty work units in a university hospital were randomized into intervention (n = 15) and control (n = 15) groups. The intervention group received monthly pain documentation audits and feedback, while the control group received no feedback. A pain knowledge test was conducted in three phases. Data were collected from February to November 2022. A linear mixed model was used to detect the effects of the REFPAD intervention.

RESULTS

The REFPAD intervention positively affected pain documentation quality, but its statistical significance was lost because of substantial within-unit variation. At baseline, pain documentation quality scores were in intervention 35% and control 38%. After 8 months of feedback, the quality scores were 44% and 43%. The number of pain assessments per patient per day was the only factor that affected pain documentation quality. The REFPAD intervention had no effect on pain knowledge.

CONCLUSIONS

The REFPAD intervention may improve pain documentation quality. A more comprehensive analysis of implementation barriers and facilitators is needed to reduce variations between and within work units.

CLINICAL IMPLICATIONS

More focus should be paid to feedback implementation and continuous monitoring of the quality of pain care is recommended.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05373641. Registration date: February 22, 2022.

The VALUE of antibiotic stewardship for companion animals: Understanding appropriate antibiotic prescribing for pet cats and dogs in veterinary clinics in Singapore

Background

Understanding the factors influencing antibiotic prescribing for pets can inform future interventions to prevent development and spillover of antimicrobial resistance (AMR) from pets to other animals, humans and the wider environment.

Material and methods

We conducted interviews with 19 veterinarians (January-July 2022) to explore factors influencing antibiotic prescribing for cats and dogs. Thematic analysis was performed using a VALUE model and themes were segmented by consultation touchpoints.

Results

We observed that veterinary clinics in Singapore heavily prioritised business viability. Existing antibiotic stewardship efforts driven by individual veterinarians were often justified as meeting pet owners' satisfaction instead. National guidelines being loosely followed, but AMR-related values and practices were mostly aligned to those of key decision-making veterinarians. Open discussions on antibiotic prescribing amongst different veterinary professionals and shared decision-making (SDM) with pet owners were common. Audits were welcomed by veterinarians but resource limitations were a major concern.

Conclusion

Recommendations to support veterinarians in prescribing antibiotics appropriately for cats and dogs range from formalising antibiotic stewardship as a clinic value, providing collective training for all veterinary professionals, continuing SDM with pet owners, automating tracking of meaningful indicators for monitoring and evaluation, and setting up a feedback system to inform behaviour change.

Stakeholders' Perspectives on Quality Measurement of Oral Health Care in the Netherlands: A Qualitative Study

OBJECTIVE

This study aimed to identify which barriers and facilitators exist and can be expected when measuring quality of oral health care according to different stakeholders in the Netherlands.

METHODS

A total of 36 semistructured interviews were conducted with dentists, patients, universities and knowledge institutes, health insurance companies, professional dental associations, and governmental health organisations. Using qualitative content analysis, barriers and facilitators were classified according to the frameworks of Grol and Cabana.

RESULTS

In total 70 barrier and 53 facilitating factors were identified in the 5 domains of the frameworks. Various stakeholders found quality measurement challenging because the quality of oral health care is difficult to define with a lack of consensus on what constitutes quality of oral health care. Patients mentioned that, for them, quality of oral health care is difficult to assess. Dentists experienced a fear of being monitored and were apprehensive of the administrative burden of quality measurement. On an organisational level, the isolation of dentistry from the medical field was mentioned as a barrier. Facilitating factors were discussing quality in a trusted environment, and developing more clinical practice guidelines, which include meaningful quality measures.

DISCUSSION

This study identified barriers and facilitators for measuring quality of oral health care in the Netherlands. Findings signal the importance of achieving consensus on the definition of quality of oral health care. Further strategy discussions about how quality of oral health care can be made insightful in a way acceptable to all stakeholders are needed to make progressions in quality improvement.

Audit and Feedback Supporting New Guideline Implementation in Chronic Kidney Disease

BACKGROUND

Adults with Type 2 diabetes mellitus and chronic kidney disease experience higher risk for progression to end stage kidney disease, which negatively impacts health, increases medical costs, and decreases quality of life.

OBJECTIVE

Determine if an audit and feedback intervention in a local nephrology clinic can increase provider adherence to a clinical practice guideline that supports the prescription of sodium glucose cotransporter-2 inhibitors to delay progression of chronic kidney disease.

DESIGN

A pretest-posttest design was used to determine if an audit and feedback tool delivered to providers at 3-week intervals would increase provider adherence to the guideline recommendation over the course of 3 months. A clinical decision guide was provided to participants at the onset of the intervention with structured interviews accompanying the audit and feedback cycles.

PARTICIPANTS

English speaking physicians and advanced practice providers were recruited from a local nephrology outpatient clinic in the southeastern United States.

MEASUREMENTS

To evaluate the significance of the intervention, a chi-square test was used to evaluate the change in prescribing of SGLT-2 inhibitors compared to the 3 months before the intervention. Logistic regression assisted with examining the relationship between the intervention and proportion of new SGLT-2 inhibitor prescriptions.

RESULTS

In this setting, statistical analysis indicated that the intervention significantly increased prescription of SGLT-2 inhibitors in adults with Type 2 diabetes and chronic kidney disease.

CONCLUSION

The intervention significantly increased provider adherence to the clinical guideline. Additional implementation on a larger scale is warranted to validate findings and further investigate barriers to prescribing that were reported by participating providers.

Development and Usability Evaluation of a Web-Based Tool for Evidence Implementation in Healthcare: PACES (Practical Application of Clinical Evidence System)

BACKGROUND

Clinicians face challenges in implementing evidence-based practices due to limited resources and tools that can support their efforts in translating evidence into practice. To address this, JBI developed PACES (Practical Application of Clinical Evidence System), an online tool designed to streamline and support evidence implementation and quality improvement projects.

OBJECTIVES

This paper reports the development of JBI-PACES and presents an evaluation of its usability (usefulness, satisfaction, ease of use) and user recommendations for improvements.

METHODS

PACES was developed based on the integration of the Donabedian perspective on quality improvement and JBI's process model for evidence implementation, which incorporates context evaluation, facilitation of change, and the evaluation of both process and outcomes. Initially launched in 2004, the system underwent multiple enhancements based on informal user feedback from 2007 to 2017. A significant update, version 0.0.23 Build 1, was re-launched in late 2018. To evaluate its usability, we conducted a cross-sectional study using the Post-Study System Usability Questionnaire (PSSUQ), which also gathered qualitative feedback.

RESULTS

PACES supports evidence implementation by allowing users to conduct audits across multiple sites and over time, enabling data comparisons and insights into clinical practices. Findings from the usability evaluation showed high levels of satisfaction with the system's usefulness and ease of use. However, qualitative data indicated areas where further enhancements could optimize user experience and functionality.

LINKING EVIDENCE TO PRACTICE

The current study suggests clear benefits of PACES in terms of its utility and value for supporting evidence-based practices. Although the system performs well in usability, ongoing refinements are necessary to optimize user experience and ensure the tool continues to meet the evolving needs of healthcare professionals.

Modeling Precision Feedback Knowledge for Healthcare Professional Learning and Quality Improvement

Healthcare providers learn continuously, but better support for provider learning is needed as new biomedical knowledge is produced at an increasing rate alongside widespread use of EHR data for clinical performance measurement. Precision feedback is an approach to improve support for provider learning by prioritizing coaching and appreciation messages based on each message's motivational potential for a specific recipient. We developed a Precision Feedback Knowledge Base as an open resource to support precision feedback systems, containing knowledge models that hold potential as key infrastructure for learning health systems. We describe the design and development of the Precision Feedback Knowledge Base, as well as its key components, including quality measures, feedback message templates, causal pathway models, signal detectors, and prioritization algorithms. Presently, the knowledge base is implemented in a national-scale quality improvement consortium for anesthesia care, to enhance provider feedback email messages.

Meta-analysis of randomized controlled trials examining social comparison as a behaviour change technique across the behavioural sciences

Research on social comparison as a behaviour change technique (SC-BCT) has increased substantially. We conducted a random-effects meta-analysis of randomized controlled trials investigating SC-BCTs across the behavioural sciences (PROSPERO: CRD42022343154). We searched MEDLINE, PsycINFO and Web of Science from inception to January 2024. Seventy-nine randomized controlled trials (N = 1,356,521) investigating effects on behaviours related to climate change mitigation, health, performance and service were included. In the short term (mean 3.7 months post-intervention), SC-BCTs produced small effects relative to both passive (Hedges' g = 0.17; 95% confidence interval, 0.11-0.23; k = 37; P < 0.001) and active control conditions (g = 0.23; 95% confidence interval, 0.15-0.31; k = 42; P < 0.001). A greater number of SC-BCT sessions and emphasis on desired (versus undesired) behaviours were associated with larger effects. Moderation effects were observed in only a few analyses, highlighting the need for further testing. SC-BCTs also produced significant small effects in the long term (mean 6.2 months post-intervention). Small effects should be interpreted in the context of low cost and scalability (for example, sending one or two emails). Certainty of evidence, using GRADE criteria, ranged from low to moderate depending on the analysis. More high-quality research is needed.

Implementing a Rapid Improvement Event with anonymised individual performance reporting on benign hysterectomy care: a retrospective comparative analysis

INTRODUCTION

Value-Based Healthcare (VBHC) aims to enhance patient outcomes while managing costs. Building on VBHC principles, the Ministry of Health Singapore introduced the Value-Driven Care programme, including initiatives like Enhanced Recovery After Surgery and Patient Blood Management. However, clinical quality remained suboptimal despite these measures due to limited clinician performance transparency. To address this, the Office of Value-Based Healthcare led a Rapid Improvement Event that implemented Individual Clinical Reports (ICRs) to provide clinicians with performance feedback. This study hypothesises that an active feedback loop using ICRs, combined with regular departmental dashboard reviews, would improve clinical quality, measured by the Clinical Quality Index (CQI).

METHODS

A quasi-experimental design compared pre-ICR and post-ICR implementation data, analysing improvements using Fisher's exact tests and logistic regression. Adjustments were made for multiple variables such as comorbidities, surgery type and American Society of Anesthesiologists classification.

RESULTS

ICR implementation significantly improved CQI performance (p=0.013) and reduced blood transfusion (p=0.046). Secondary outcomes, including length of stay, complications and readmission rates, also showed improvements with trends towards significance.

CONCLUSION

An active feedback loop consisting of ICRs and multidisciplinary team discussions enhanced CQI for hysterectomy patients at a tertiary hospital in Singapore. They represent a valuable feedback tool with the potential to improve care quality in other standardised surgeries.

Effect of a multifaceted intervention with audit and feedback on low-risk childbirth practice: a multicentre prospective study

BACKGROUND

Care for low-risk childbirths constitutes a large proportion of deliveries and is highly influenced by factors such as region, birthing facilities, and health care providers. Audit and feedback as a quality indicator (QI) intervention alone have limited effectiveness. Multidisciplinary approaches, including QI and organizational development, are reportedly effective; however, the impact on low-risk childbirth care remains unclear. We aimed to assess the impact of multifaceted intervention, including audit and feedback, on improving care for low-risk childbirths using QIs.

METHODS

We conducted a 1-year pre-post comparison targeting healthy pregnant women in four obstetric wards in Japan. The intervention included audit and feedback combined with multifaceted approaches, improvement efforts by a multidisciplinary team, and educational training on health care quality and organizational culture. The outcomes were 12 QIs. The main analysis used interrupted time-series analysis over 6 months pre- and post-intervention. We compared the 9 months pre-intervention with 3 months post-intervention in secondary analysis to assess delayed effects.

RESULTS

We included 288 women pre-intervention and 167 women post-intervention. "The spontaneous vaginal delivery indicator showed a significant increase in slope (risk ratio [RR] 1∙08, 95% confidence interval [CI]: 1∙00-1∙16, p < 0∙05), indicating a trend-based improvement rather than an immediate change per month in the main analysis. Secondary analysis showed a significant increase in the administration of uterotonic agents during the third stage of labour (RR 1∙19, 95% CI: 1∙01-1∙41, p < 0∙05).

CONCLUSION

The improvement effects of multifaceted interventions, including audit and feedback, using QIs for low-risk childbirths were limited. However, some indicators may improve over time, suggesting a potential delayed effect.

TRIAL REGISTRATION

Not applicable.

When the parts are greater than the whole: how understanding mechanisms can advance implementation research

BACKGROUND

Does the importance of context in implementation imply that generalizing about the effects of strategies is ultimately limited? Conceptual approaches for generalizing in the presence of significant contextual heterogeneity could advance implementation research but require novel perspectives.

MAIN BODY

Drawing from perspectives from Realist approaches, Pearl's transportability framework and philosophy of science, this paper outlines a mechanism-based approach to generalizing about the effects of implementation strategies. We suggest that understanding mechanisms creates a conceptual bridge between the effects of a strategy and the influence of the implementation context. Using directed acyclic graphs to represent the mechanisms of strategies, we show how conceptualizing mediators of overall effects offer a basis for considering the effects of context. Hence, theorizing and testing a mechanistic understanding enriches the ways in which we can consider how context could change those effects. Such an approach allows us to understand how a strategy works within a given implementation context, determine what information from new contexts are needed to infer across contexts, and if that information is available, what those effects would be - thereby advancing generalizing in implementation research. We consider particular implementation strategies (e.g., Community Adherence Groups and practice facilitation) as examples to illustrate generalizing into different contexts.

CONCLUSION

Mechanisms can help implementation research by simultaneously accommodating the importance of context as well as the imperative to generalize. A shift towards a mechanism-focused approach that goes beyond identifying barriers and facilitators can enhance the value of implementation research.

Evaluating Feasibility and Acceptability of the "My HeartHELP" Mobile App for Promoting Heart-Healthy Lifestyle Behaviors: Mixed Methods Study

Background

Few mobile apps have strategies for self-monitoring multiple heart-healthy behaviors simultaneously, as well as automated and tailored feedback on individual behavioral outcomes for cardiovascular health. An app named "My HeartHELP" was developed for the general adult population to promote 6 heart-healthy lifestyle behaviors-physical activity, nonsedentary behaviors, healthy eating behaviors, nonsmoking, no alcohol binge drinking, and self-assessment of body weight. Three behavioral strategies were used: (1) text messaging the users for information on cardiovascular health, (2) self-monitoring of 6 heart-healthy behaviors to fill out the blanks of behavioral items, and (3) automated and tailored feedback messaging to users for behavioral outcomes obtained from self-monitoring.

objectives

This study aimed to evaluate the feasibility and acceptability of the "My HeartHELP" app.

Methods

The participants were 29 community residents in Seoul, South Korea, who met at least 1 criterion of metabolic syndrome. To evaluate the feasibility, we assessed 3 records, which are as follows: First, the "record for self-monitoring" was determined as feasible if an average percentage for each of the 6 behaviors over 4 weeks was 75% or higher based on percentages of participants who completed to record each of 6 heart-healthy behaviors. Second, the "record for access to the app" was determined as feasible if users accessed at least once a day on average per week. Third, "records for behavioral changes" over 4 weeks were collected via a self-reported questionnaire. To evaluate acceptability, we used an assessment tool comprising 12 items that included subscales for comprehensibility, ease, health benefits, technical completeness, overall satisfaction, and recommendation to others on a 5-point Likert scale. Acceptability was determined as acceptable if the average scores for the total scale and each subscale were 3.5 points or greater. Second, qualitative data were collected through 2 focus groups, each consisting of 14 or 15 participants. All data were collected in June and July 2022.

Results

During the 4 weeks, 95.6% (range: 85.8%-97.4%) of the participants adhered to more than 75% of "completion of daily self-monitoring of each heart-healthy behavior," having met the criterion. The participants accessed the app on average 1.8 (SD 1.70) times per day, meeting the criteria. Participants had positive behavioral changes in all 6 behaviors, of which nonsedentary behavior (10%-28%; χ21=1.76; P<.001) and non-fast-food intake were especially statistically significant (72%-93%; χ21=5.64; P=.03) over 4 weeks. Participants reported 3.8 points for a total score of acceptability and more than 3.5 points for all subscales, which met the criterion. Qualitative data obtained from focus groups indicated that automated and tailored feedback messages motivated participants to promote healthy lifestyles.

Conclusions

The "My HeartHELP" app may be a feasible and acceptable mobile app to promote self-monitoring and possibly behavioral changes in heart-healthy lifestyle behaviors.

A standardized set of metrics to assess the quality of anesthesia, perioperative care, and acute pain management in Canada: a multidisciplinary modified Delphi study

PURPOSE

The aim of this study was to develop a consensus list of metrics to measure the quality of care in anesthesia, perioperative care, and acute pain management in Canada.

METHODS

We sought to conduct a modified Delphi study involving a multidisciplinary panel of perioperative health care professionals (anesthesiologists, surgeons, nurses, internal medicine and family medicine physicians, and hospital administrators), patients, and caregivers. Participants reviewed a candidate list of metrics synthesized from a previous scoping review and performed three rounds of independent iterative scoring and feedback to achieve consensus. In round 3, we asked participants to identify priority metrics to include in a list of core metrics, and we also asked health care professionals to assess the feasibility of implementing each metric.

RESULTS

There were 80 participants (49 health care professionals, 22 patients, and 9 caregivers) who completed at least one round of voting, with 56 completing all three rounds. The panel achieved consensus on 87 metrics, of which they deemed 33 to be priority core metrics. The health care professional and patient/caregiver subgroups differed in prioritizing core metrics. Most participants voted airway complications, no residual neuromuscular blockade, difficult airway documentation, complication or critical incident reporting, and complications from pain management the highest priority metrics. Most health care professional participants considered the core metrics to be already measured, currently feasible, or likely feasible by 2025.

CONCLUSIONS

A multidisciplinary panel developed a list of metrics for measuring the quality of anesthesiology care in Canada. Many metrics require further refinement and validation, and future research is required to guide the measurement techniques and implementation approaches.

Metrics to assess the quality of anesthesia, perioperative care, and acute pain management in Canada: a scoping review

PURPOSE

The aim of this scoping review was to consolidate a list of metrics that can be used to measure quality in anesthesiology, perioperative medicine, and acute pain management in Canada.

METHODS

We included English-language full-text articles involving metrics (including patient-reported outcome and patient-reported experience measures, quality and safety indicators, and practice standards) for adults aged 18 yr and older undergoing inpatient non-cardiac surgery requiring an anesthesiologist. We searched MEDLINE®, Embase, CINAHL, Web of Science™, the Cochrane Database of Systematic Reviews, and grey literature to find articles on the topic from January 2015 to March 2022. In addition, we contacted 64 Canadian hospitals for existing anesthesia quality assurance and improvement metrics; they responded from June to October 2022. Two independent reviewers performed screening and data extraction. We grouped and condensed similar candidate metrics using thematic analysis.

RESULTS

We assessed 4,493 publications, of which 63 met the inclusion criteria. We extracted 662 candidate metrics and consolidated them into 94 distinct metrics. Metrics reflected themes of perioperative management (n = 47), safety and standards (n = 23), patient-centredness (n = 11), intraoperative anesthetic care (n = 5), perioperative team leadership (n = 4), and efficiency (n = 4). Metrics spanned all quality-of-care categories (process, outcome, and structure) and perioperative phases but were limited by poor supporting evidence.

CONCLUSIONS

We consolidated a list of 94 metrics that can be used to evaluate the quality of anesthesia care. Further work will require verification of feasibility and validity prior to adoption, with operationalization of these metrics into practical indicators that are measurable and comparable.

Outcomes of an organisational change program aimed at increasing smoking cessation support within Australian community managed mental health organisations: A cluster randomised controlled trial

AIM

To test the effectiveness of an organisational change intervention aimed at increasing the offer of nicotine replacement therapy (NRT) in community managed mental health organisations.

DESIGN

A pragmatic cluster randomised controlled trial with cluster as the unit of randomisation and six- and nine-month follow-up from baseline.

SETTING

Twelve clusters comprising 26 sites providing community based, psychosocial support to people with severe mental illness in New South Wales, Australia, were randomised to control (n = 13 sites, n = 118 consumers) or intervention (n = 13 sites, n = 139 consumers) arms between 2018 and 2019.

PARTICIPANTS

Eligible consumers (aged 16 years and older; self-reported daily or occasional cigarette use) completed surveys at baseline (n = 257) and at six- (n = 162, 63%) and nine-month follow-up (n = 144, 56%).

INTERVENTION

The intervention included a financial grant, face-to-face and on-line training and proactive monthly support to guide implementation. The active control condition included on-line training and generic, scheduled support via email.

MEASUREMENTS

The primary outcome was whether consumers reported receiving an offer of NRT at nine-month follow-up. Secondary outcomes at the consumer, staff and organisational level were also measured.

FINDINGS

Consumers in the intervention group had statistically significantly higher odds of being offered NRT at nine-month follow-up compared with control (intention to treat missing = no offer: 38% versus 7%, odds ratio 5.72, 95% confidence interval = 2.2, 14.9). There were no statistically significant differences in seven-day point prevalence or continuous abstinence at six- or nine-month follow-ups.

CONCLUSIONS

An organisational change-based program led to an increase in the offer of nicotine replacement therapy (NRT) nine months after program initiation in community managed mental health organisations, compared with active control. There was evidence of greater NRT use in the intervention condition at nine months but no evidence of differences on abstinence measures at six or nine months.

Enhancing implementation of information and communication technologies for post-discharge care among hospitalized older adult patients: development of a multifaceted implementation intervention package using the behavior change wheel and implementation research logic model

BACKGROUND

The integration of information and communication technologies in clinical practice can supplement traditional care pathways on discharge education and has exhibited evident benefits in improving patient health outcomes. However, healthcare providers have reported difficulties in adopting such technologies. The existing evidence on implementation interventions supporting the implementation of information and communication technologies is insufficient, characterized by infrequent utilization or reporting of implementation theories in implementation intervention designs. This study aims to outline the creation of a theory-informed implementation intervention package to enhance the clinical implementation of information and communication technologies for post-discharge self-care among hospitalized older adults.

METHODS

This study systematically applies the Behavior Change Wheel (BCW) approach, involving behavior diagnosis, identification of intervention options, and intervention content selection, informed by conceptual frameworks, empirical data, and relevant literature. Additionally, the Implementation Research Logic Model is utilized to synthesize, organize, and visually present the collected data.

RESULTS

This structured process identified and selected five intervention functions, 11 behavior change techniques, and four policy categories. A multifaceted implementation intervention package was developed, containing four components: (i) flexible and sustainable training, (ii) mass media and opinion leader campaign, (iii) technology and workflow redesign, and (iv) regular corporate-level audit and feedback.

CONCLUSIONS

The study addresses the incomplete evidence base for implementation interventions supporting clinical information and communication technology implementation, presenting a practical, evaluable, and scalable theory-informed implementation intervention package. By providing an example of the application of the BCW approach and logic model, this study contributes to the knowledge on implementation intervention design, offering valuable insights for researchers and practitioners aiming to improve healthcare providers' behavior change and post-discharge care management with technology-based interventions.

Future Health Today and patients at risk of undiagnosed cancer: a pragmatic cluster randomised trial of quality- improvement activities in general practice

BACKGROUND

Diagnosing cancer in general practice is complex, given the non-specific nature of many presenting symptoms and the overlap of potential diagnoses.

AIM

This trial aimed to evaluate the effectiveness of Future Health Today (FHT) - a technology that provides clinical decision support, auditing, and quality-improvement monitoring - on the appropriate follow-up of patients at risk of undiagnosed cancer.

DESIGN AND SETTING

Pragmatic, cluster randomised trial undertaken in general practices in Victoria and Tasmania, Australia.

METHOD

Practices were randomly assigned to receive recommendations for follow-up investigations for cancer (FHT cancer module) or the active control. Algorithms were applied to the electronic medical record, and used demographic information and abnormal test results that are associated with a risk of undiagnosed cancer (that is, anaemia/iron deficiency, thrombocytosis, and raised prostate-specific antigen) to identify patients requiring further investigation and provide recommendations for care. The intervention consisted of the FHT cancer module, a case-based learning series, and ongoing practice support. Using the intention-to-treat approach, the between-arm difference in the proportion of patients with abnormal test results who were followed up according to guidelines was determined at 12 months.

RESULTS

In total, 7555 patients were identified as at risk of undiagnosed cancer. At 12 months post-randomisation, 76.0% of patients in the intervention arm had received recommended follow-up (21 practices, n = 2820/3709), compared with 70.0% in the control arm (19 practices, n = 2693/3846; estimated between-arm difference = 2.6% [95% confidence interval (CI)] = -2.8% to 7.9%; odds ratio = 1.15 [95% CI = 0.87 to 1.53]; P = 0.332).

CONCLUSION

The FHT cancer module intervention did not increase the proportion of patients receiving guideline-concordant care. The proportion of patients receiving recommended follow-up was high, suggesting a possible ceiling effect for the intervention.

mHealth Apps Available in Italy to Support Health Care Professionals in Antimicrobial Stewardship Implementation: Systematic Search in App Stores and Content Analysis

Background

Antimicrobial resistance (AMR) is a major challenge of the 21st century. Digital technologies are now an increasingly effective means of supporting optimal health care delivery and public health.

Objective

The aim of this study was to explore the apps available to support health care professionals in the fight against AMR.

Methods

A total of 4 independent researchers conducted a systematic search of the App Store and Google Play Store using the following keywords: "antimicrobial resistance," "antibiotic resistance," "antimicrobial stewardship," "antibiotic stewardship," "antibiotic guide," "antibiotic therapy," and "antimicrobial therapy." The same keywords were also searched in Italian. The apps whose contents were in languages other than Italian or English, or apps which were games, or had multimedia or paid content and advertising, or apps for only specific pathologies were not considered. A set of basic information was collected for all apps found. After downloading the apps, they were evaluated using an 86-item checklist containing expert-validated criteria aggregated in the domains of pathogens and etiological agents, diagnosis and therapy support, AMR, dashboard function, antimicrobial stewardship (AMS), notes and recordings, network, and technical characteristics of the app.

Results

First, 115 apps were identified: 31 apps for Android and 84 apps for iOS. By applying the exclusion criteria, 31 apps were excluded (16 for Android and 15 for iOS) for the following reasons: not available in Italian or English (6 apps), not freely available (14 apps), required registration (5 apps), and games (6 apps). The remaining 84 eligible apps (15 for Android and 69 for iOS) were downloaded, installed, and further analyzed using the same criteria, excluding 57 apps (48 for iOS and 9 for Android) for the following reasons: required further registration (16 apps), language other than Italian or English (17 apps), pathology specific (5 apps), paid content (8 apps), specific to veterinarians (4 apps), recreational apps (2 apps), referred to only scientific articles (1 app), no longer available (1 app), and not health care objectives (3 apps). The remaining 27 apps (6 for Android and 21 for iOS) were selected for in-depth analysis. Of the 27 apps that met the inclusion criteria, most apps did not fulfill the desirable aspects and only 2 of them achieved a fulfillment score of 36%. The highest scores were achieved for support for diagnosis and therapy (37%) and technical characteristics of the app (23%). Lower scores were achieved for AMS (8%), pathogens and etiological agents (4%), notes and records (3%), network (2%), AMR (1%), and dashboard function (1%).

Conclusions

None of the apps examined successfully provided the desired features and functions. To better engage of prescribers in the fight against AMR, the development of an app that meets the requirements is needed.

Enhancing primary care quality improvement through national data collection and validation: the primary care quality initiative in Sweden

OBJECTIVE

Quality measures in healthcare are crucial for improving outcomes and ensuring patient safety. This study investigated the evolution, implementation, and impact of Primary Care Quality (PCQ). The PCQ aims to facilitate nationwide quality benchmarking, serving as a tool for quality improvement (QI) and research.

DESIGN/SETTINGS

A descriptive design outlining the development and operationalisation of the PCQ, a national framework for automatic and systematic data collection and feedback.

RESULTS

The national PCQ system is a tool for continuous QI in primary care in Sweden. PCQ has achieved extensive adoption, with over 97% of Swedish primary care centres, both private and public driven, utilising the platform for automatic data extraction from patient records and data visualisation. Quality indicators were developed through a structured approach involving primary care professionals, evidence-based clinical practices, and expert contributions from established knowledge organisations, reflecting the breadth of general practice. Data are automatically retrieved from medical records and visualised in real time, with the possibility of benchmarking at an aggregate level and identifying individuals locally at primary care centres. The PCQ has facilitated improvements by enabling quality dialogue among healthcare professionals and supporting continuous local QI. Regionally, the PCQ supports needs assessments and patient safety initiatives. Nationally, it establishes standardised indicators for quality measurement, enabling effective benchmarking and strategic healthcare planning.

CONCLUSIONS

The implementation of the national PCQ system provided a framework and tool for continuous QI in primary care. The system has influenced national standardization of primary care indicators, with quality improvement results demonstrated regionally and locally through the PCQ.

Assessment of the impact of power business intelligence on adenoma detection rate: a prospective observational trial

BACKGROUND

Adenoma detection rate (ADR) is a key quality indicator in colonoscopy, with low ADRs linked to higher risks of post-colonoscopy colorectal cancers. Feedback to endoscopists has been shown to improve ADRs; however, many feedback systems lack automation and real-time interactivity. This study evaluates the effectiveness of Power Business Intelligence (Power BI) on ADR enhancement.

METHODS

This prospective observational study compared ADRs before (2021) and after (2022) the implementation of Power BI at Dalin Tzu Chi Hospital, Taiwan. Power BI automatically processed pathology data to calculate ADRs and provided real-time visual feedback on endoscopy quality indicators. A total of 4,306 colonoscopies performed by 10 endoscopists were analyzed. Logistic regression was employed to identify factors associated with ADR.

RESULTS

The overall ADR was high and comparable between the periods without and with Power BI (50.1% vs. 47.9%, P = 0.152). Individual performance was stable, though one low-performing endoscopist improved ADR by 20.0%. Adjusted multivariate analysis found no association between Power BI and ADR. Higher ADRs correlated with male gender (odds ratio [OR], 1.638; 95% confidence interval [CI], 1.438-1.864; p < 0.001), advanced age (OR, 1.642; CI, 1.439-1.875; p < 0.001), elevated BMI (OR, 1.642; CI, 1.439-1.875; p < 0.001), and positive stool occult blood (OR, 1.829; CI, 1.545-2.167; p < 0.001). Effective technical practices for improving ADRs included polyethylene glycol preparation (OR, 1.246; CI, 1.063-1.462; p = 0.007), water-method colonoscopy (OR, 1.321; CI, 1.134-1.538; p < 0.001), and withdrawal times ≥ 6 min (OR, 6.370; CI, 5.179-7.837; p < 0.001).

CONCLUSIONS

The use of Power BI was not associated with a higher ADR at a high-performing institution but may benefit low-performing endoscopists. Efforts should target behavioral changes in modifiable technical factors to drive meaningful ADR improvements.

Does point-of-care ultrasound examination by the general practitioner lead to inappropriate care? A follow-up study

BACKGROUND

The use of point-of-care ultrasound (POCUS) in general practice increases, but little is known about potential unintended findings and harms to patients. Information regarding such unwanted effects may be obtained by evaluating the medical records of patients who have been scanned by their general practitioner.

OBJECTIVE

To identify and characterize re-consultations related to POCUS use in general practice, potential misdiagnosis, overdiagnosis, and incidental findings, and to compare potentially troublesome cases to GPs' scanning competence and type of ultrasound device.

DESIGN AND SETTING

Professors in general practice with extensive experience in both research and quality assurance in general practice did a blinded review of prospectively collected routine electronic medical record data combined with cross-sectional data collected in relation to POCUS examinations.

SUBJECTS

Twenty general practitioners collected data on 564 patients examined with POCUS in primary care.

MAIN OUTCOME MEASURES

International standards for the classification of adverse events and incidental findings were used. First, research assistants identified all re-consultations described in the medical records that were related to the primary health complaint at the index consultation. Second, these re-consultations were classified by the medical experts in terms of seriousness and relation to the POCUS examination performed at the index consultation. In addition, the experts identified possible misdiagnosis, possible overdiagnosis, and incidental findings. Finally, identified cases were discussed in terms of appropriateness and described narratively.

RESULTS

Medical records of 564 patients were reviewed. A low risk of possible misdiagnosis (5.3%), potential overdiagnosis (0.7%), and incidental findings (0.7%) were found. Eleven POCUS-related re-consultations were identified and described.

CONCLUSION

POCUS scanning performed by general practitioners was generally safe, but it can result in unnecessary examinations and potential harm in a few cases. Certain areas, e.g. pelvic scans that included the ovaries, may especially be prone to misdiagnosis.

TRIAL REGISTRATION NUMBER

NCT03375333.

Untangling feedback: Mapping the patterns behind the practice

Although feedback is widely recognized as essential to improving performance and learning outcomes, what feedback involves and what it achieves can vary significantly according to researchers and practitioners. This variability reflects the lack of a shared conceptual framework to unite feedback practices, theories, findings and recommendations. In this paper, the authors use a recently developed pattern system to compare different models of feedback as a way of building a more united perspective. The authors conducted a comparative case study and framework analysis of 11 feedback models across four categories of feedback (augmented sensorimotor feedback, coaching, audit and feedback and multisource feedback). Each model was analysed to identify which aspects of feedback it addressed, and which were overlooked or excluded. The analysis revealed both divergence and convergence in how feedback models mapped onto the pattern system. Divergence was evident in the variability of elements (pattern representations) across models and diversity in expression and granularity of those elements. Conversely, convergence was observed in recurring clusters of elements, such as Performance measurement, Sensor, Judgement and Assessment, which appeared consistently across categories. Overall, the mapping exercise showed significant variations in how feedback is conceptualized, even within specific subcategories such as "coaching," "audit and feedback" and "multisource feedback." These differences have important implications for advancing research and practice in these areas. Pattern theory and pattern mapping offer a promising framework for exploring and addressing the conceptually contested nature of feedback in medical education and may facilitate the future development of a pattern language of feedback.

Re-Think the Strip: de-implementing a low value practice in primary care

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a low value health care practice that does not benefit most patients with non-insulin treated type 2 diabetes (T2DM). This paper evaluates Re-Think the Strip (RTS), a multi-component study aimed at de-implementing SMBG among non-insulin treated T2DM patients in primary care.

METHODS

This study used a pre-post design to evaluate the effectiveness and implementation of Re-Think the Strip in 20 primary care clinics with a comparison group of 34 clinics within one health system. De-implementation strategies were implemented over 12 months and practices were followed for 18 months.

RESULTS

There was an overall decrease in the odds of receiving a prescription for diabetes testing supplies (i.e., test strips and/or lancets) between the baseline and 12-month intervention follow-up for intervention and comparison clinics (OR 0.96, 95% CI 0.94, 0.98). However, there was no statistically significant difference in prescribing between the intervention and comparison clinics. In sensitivity analyses, a small intervention effect was observed for those patients newly diagnosed with T2DM or newly assigned to a study clinic (OR = 0.97, 95% CI 0.95, 1.00).

CONCLUSIONS

De-implementation strategies are feasible in primary care practices. Although prescriptions for SMBG decreased in intervention practices, they also decreased in the comparison practices. Newly diagnosed patients or new patients may be more receptive to de-implementation. Other factors, including the COVID-19 pandemic and baseline prescribing rates may have limited the effectiveness of the RTS de-implementation strategy.

How hospitals' goal setting, feedback, and process standardization capacity impact provider payment reforms

BACKGROUND

Provider payment reforms (PPRs) can improve providers' efficiency, but they often generate mixed results. Since organizations mediate PPR effectiveness, examining hospitals' management capacity's association with PPR effectiveness can be useful. In the context of clear strategies, hospitals' management characteristics related to goal attainment would be key to PPR adaptation. This study examines hospitals' capacity to set goals at appropriate difficulty or specificity, provide feedback, or standardize processes.

METHODS

We leverage a matched-pair, cluster randomized controlled PPR trial in a low-income Chinese province between 2014 and 2018. The reform aimed to reduce the per admission expenditure of the public insurance New Cooperative Medical Scheme (NCMS) though this may inadvertently trigger higher out-of-pocket (OOP) expenditure. We categorize 52 hospitals' baseline goal setting, feedback, and process standardization capacities using the World Management Survey and interact these characteristics with the difference-in-difference estimator to examine whether the four management characteristics modified the treatment effect.

RESULTS

All four management characteristics were non-statistically significantly associated with lower NCMS expenditure growth, consistent with the PPR incentives. However, their effects were jointly significant. Much of the effect came from goal specificity and feedback. Regarding expenditure shifting to OOP sources, only process standardization amplified such behaviour while goal difficulty showed spillover control in OOP expenditure growth.

CONCLUSION

Management capacity around goal attainment is an important moderator of PPR effectiveness, and future research can further unpack organizational characteristics of PPRs. Policymakers and hospital leaders may use industry peer networks to disseminate high quality goal development approaches and encourage huddles to facilitate feedback. Introducing monitoring and penalties for expenditure shifting-particularly for hospitals that can standardize operations in pursuit of profit-may be helpful.

Improving Pediatric Surgical Follow-Up Documentation: A Prospective Clinical Audit in the Department of Pediatric Surgery at National Ribat University Hospital, Sudan

BACKGROUND

Proper clinical documentation is essential for patient safety and the continuity of care, especially in pediatric surgery. In a resource-limited setting at Ribat University Teaching Hospital in Khartoum, Sudan (2021-2022), this study looked at how well the B-SOAP (short for Background, Subjective, Objective, Assessment, and Plan) follow-up documentation structure was followed. Baseline audits identified significant flaws, with a 21.9% (21 out of 96) adherence rate, highlighting systemic shortcomings in organized documentation standards.

MATERIALS AND METHODS

We performed a prospective observational audit over three cycles (pre-intervention, intervention, and post-intervention), examining 68 B-SOAP sheets. Cause-and-effect diagrams and Pareto charts used in pre-intervention audits showed that the main problems were a lack of standard templates, poor training, and monitoring that wasn't consistent. Interventions comprised the revision of the B-SOAP template, the implementation of training sessions, and the establishment of audit feedback mechanisms. Compliance was evaluated by descriptive statistics, utilizing a 90% standard for completeness and correctness.

RESULTS

Post-intervention compliance increased markedly to 90% (22 out of 24) (Δ+68.1%), exceeding objectives. The most significant improvement was seen in the Plan part, which went from 32.5% (seven out of 21) to 65% (14 out of 22). This was followed by the Subjective (21.2%, from four out of 21 to nine out of 22) and Assessment (21.0%, from two out of 21 to seven out of 22) parts. The documenting of objectives continued to be difficult (+16.4%), indicating ongoing obstacles to uniform data entry. Iterative audits and systematic feedback facilitated gradual improvements, consistent with evidence about the effectiveness of audits in resource-constrained environments.

CONCLUSION

Structured interventions, such as standardizing templates, training, and regular audits, greatly increased B-SOAP compliance, showing that it is possible to do so with paper-based systems. Despite problems with the infrastructure, the fact that 90% of the people who were supposed to follow the rules did so after the intervention shows how important it is to improve quality in a planned way. Maintaining progress necessitates continuous education, regular audits, and scalable digital solutions. This study gives a framework that can be used again and again to improve clinical documentation in similar settings with limited resources. This will immediately improve patient safety and care quality.

Core medication use in general practice prescriptions: A pilot study evaluating the Drug Utilization 90% Index in Irish general practice

AIMS

The Drug Utilization 90% Index (DU90%), the number of medicines making up 90% of a doctor's prescribing, is a simple tool that can be used to describe core prescribing patterns. This research aimed to pilot the application of the DU90% in the Irish context, to investigate the relationship between the DU90% and prescriber and practice characteristics and prescribing quality.

METHODS

Retrospective observational study using anonymous prescription data from a sample of Irish general practitioners (GPs). Participating GPs provided demographic details and extracted prescription data for 2018-2022 using their existing software systems. The DU90% was calculated annually at both the practice and prescriber level. Prescribing quality indicators included antibiotic, benzodiazepine prescribing rates and high-risk nonsteroidal anti-inflammatory drug prescribing. The association of the DU90% with prescriber and practice characteristics and prescribing quality indicators was explored with multilevel modelling.

RESULTS

Thirty-eight prescribers from 22 different practices were included. The mean DU90% for prescribers was 141.5 (standard deviation 12.9) and for practices was 145.62 (standard deviation 11.87). Practices in receipt of the rural deprivation grant had a significantly lower DU90% (incidence rate ratio 0.94, 95% confidence interval 0.88-0.98). There was no evidence of an association between prescriber-level characteristics and the DU90% (sex, years qualified, number of sessions worked). There was a small positive relationship between the prescriber DU90% and total prescriptions, antibiotic and benzodiazepine prescribing rates, and higher rates of high-risk nonsteroidal anti-inflammatory drug prescriptions.

CONCLUSION

Applying the DU90% to Irish general practice prescriptions is feasible, revealing that GPs typically use 140 medicines in the bulk of their prescribing.

Evaluation of Co-Developed Strategies to Support Staff of a Mental Health Community Managed Organisation Implement Preventive Care: A Pilot Controlled Trial

BACKGROUND

Mental health community managed organisations (CMOs) are well placed to provide preventive care, including behaviour change conversations to address smoking, nutrition, alcohol and physical activity (snap). This study evaluates the impact of co-developed preventive care implementation support strategies, including Healthy Conversation Skills (HCS) training on CMO staff attitudes and perceptions relating to preventive care for snap behaviours.

METHODS

A non-randomised controlled pilot trial was undertaken (October 2021-May 2022) with two branches of a mental health CMO (n = 1 target; n = 1 control) in NSW, Australia. Target group staff received a three-month implementation support package co-developed by staff and researchers, including HCS training and educational materials. Staff from both groups completed an online survey at baseline and follow-up, reporting barriers and facilitators and perceived individual and organisational ability to provide preventive care for each behaviour. Pre and post HCS training, target staff completed surveys reporting barriers and facilitators to having behaviour change conversations, and competency of using 'open discovery questions' (a key HCS skill).

RESULTS

Baseline (n = 27) and follow-up (n = 17) surveys showed mean scores increased for the target group and decreased for the control group for n = 4/8 barrier and facilitator outcomes, and n = 7/8 perceived individual and organisational ability of providing care outcomes. Sixteen target group staff participated in HCS training and surveys, with scores improving for skills (p = 0.0009), beliefs about capabilities (p = 0.0035), intentions (p = 0.0283), participant confidence (p = 0.0043), perceived usefulness (p = 0.004), and competence in using open discovery questions (p < 0.0001).

CONCLUSIONS

This pilot trial demonstrates the feasibility and potential effectiveness of a co-developed implementation support package at increasing mental health CMO staff capacity to provide preventive care for multiple health behaviours. SO WHAT?: This evidence can inform future research trials and health policy aimed at supporting CMO staff in delivering comprehensive preventive care.

Evidence-Informed Quality Indicators for Pediatric Trauma Care

Importance

Despite the unique physiological characteristics and health care needs of pediatric trauma patients, there is a lack of quality indicators (QIs) based on pediatric-specific evidence to support quality improvement in this population.

Objective

To develop a consensus-based set of QIs for acute pediatric trauma care that considers evidence on effectiveness, safety, cost-effectiveness, equity, and caregiver perspectives and is applicable in pediatric and nonpediatric trauma centers.

Design, Setting, and Participants

A modified Research and Development (RAND)/University of California Los Angeles (UCLA) expert consensus study was conducted consisting of an online survey and a virtual workshop, led by an independent moderator. Panelists represented key areas of pediatric trauma patient management, diverse care settings (from level I pediatric trauma centers to level III referring centers), 5 high-resource countries, and caregivers. Data were analyzed from May to August 2024.

Exposure

Likert-scale ratings of 41 QIs.

Main Outcomes and Measures

Panelists rated 41 QIs on a 7-point Likert scale according to 4 criteria: importance, supporting evidence, actionability, and measurability. QIs with a global score of 24 of 28 or greater and an importance score of 6 of 7 or greater were considered accepted by consensus.

Results

A total of 65 experts were invited, of whom 59 accepted (91%; 25 over 50 years of age [44.7%]; 34 female [60.7%]), 56 (95%) completed the first round, and 54 (92%) completed both rounds. Twenty-three QIs were selected covering key areas of acute pediatric trauma management (eg, transfer to a pediatric trauma center for neurotrauma or major multisystem trauma, documentation of vital signs, early rehabilitation, nutritional support), the most common types of injuries (eg, hypertonic saline in severe traumatic brain injury, stabilization of femoral shaft fractures, nonoperative management of solid organ injuries), value in care (eg, imaging in children at low risk on a clinical decision rule), patient-centered care (eg, designated support person, caregiver presence), and equity (eg, mental health screening).

Conclusions

These results may be used by trauma quality improvement programs in high-resource countries to select context-specific quality indicators to improve the effectiveness, safety, cost-effectiveness, equity, and patient-centered nature of pediatric trauma care.

Effect of a multifaceted intervention on potentially unnecessary antibiotic prescriptions in general practice, out-of-hours services, and nursing homes in Spain

OBJECTIVE

To evaluate the impact of a multifaceted antimicrobial stewardship intervention on potentially unnecessary antibiotic prescribing.

MATERIAL AND METHODS

Before and after quality control study carried out in three different settingsgeneral practice, out-of-hours services, and nursing homesin Spain. Healthcare professionals (both doctors and nurses) self-registered common infections using a specific template for each setting before (2022) and after (2023) receiving a 5-hour intervention on prudent antibiotic use.

RESULTS

Eighty-nine professionals participated in the first registration (48 in general practice, 23 in out-of-hours services, and 15 in nursing homes), with 71 (79.8%) completing the intervention and second registration. Potentially unnecessary antibiotic prescriptions were 68.5%, 41.7%, and 77.7% in the first registration, respectively, and 61.4%, 34.8%, and 86.8% after the intervention, showing reductions of 10.4% in general practice and 16.5% in out-of-hours services, and an 11.7% increase in nursing homes, albeit without statistically significant differences.

CONCLUSIONS

The study found that this intervention slightly improved antibiotic use, with minimal impact, but worsened in nursing homes.

Audit and feedback: effects on professional practice

BACKGROUND

Audit and feedback (A&F) is a widely used strategy to improve professional practice. This is supported by prior Cochrane reviews and behavioural theories describing how healthcare professionals are prompted to modify their practice when given data showing that their clinical practice is inconsistent with a desirable target. Yet there remains uncertainty regarding the effects of A&F on improving healthcare practice and the characteristics of A&F that lead to a greater impact.

OBJECTIVES

To assess the effects of A&F on the practice of healthcare professionals and to examine factors that may explain variation in the effectiveness of A&F.

SEARCH METHODS

With the Cochrane Effective Practice and Organisation of Care (EPOC) group information scientist, we updated our search strategy to include studies published from 2010 to June 2020. Search updates were performed on 28 February 2019 and 11 June 2020. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Library, clinicaltrials.gov (all dates to June 2020), WHO ICTRP (all dates to February Week 3 2019, no information available in 2020 due to COVID-19 pandemic). An updated search and duplicate screen was completed on February 14, 2022; studies that met inclusion criteria are included in the 'Studies awaiting classification' section.

SELECTION CRITERIA

Randomised trials, including cluster-trials and cross-over and factorial designs, featuring A&F (defined as measurement of clinical performance over a specified period of time (audit) and provision of the resulting data to clinicians or clinical teams (feedback)) in any trial arm that reported objectively measured health professional practice outcomes.

DATA COLLECTION AND ANALYSIS

For this updated review, we re-extracted data for each study arm, including theory-informed variables regarding how the A&F was conducted and behaviour change techniques for each intervention, as well as study-level characteristics including risk of bias. For each study, we extracted outcome data for every healthcare professional practice targeted by A&F. All data were extracted by a minimum of two independent review authors. For studies with dichotomous outcomes that included arms with and without A&F, we calculated risk differences (RDs) (absolute difference between arms in proportion of desired practice completed) and also odds ratios (ORs). We synthesised the median RDs and interquartile ranges (IQRs) across all trials. We then conducted meta-analyses, accounting for multiple outcomes from a given study and weighted by effective sample size, using reported (or imputed, when necessary) intra-cluster correlation coefficients. Next, we explored the role of baseline performance, co-interventions, targeted behaviour, and study design factors on the estimated effects of A&F. Finally, we conducted exploratory meta-regressions to test preselected variables that might be associated with A&F effect size: characteristics of the audit (number of indicators, aggregation of data); delivery of the feedback (multi-modal format, local champion, nature of comparator, repeated delivery); and components supporting action (facilitation, provision of specific plans for improvement, co-development of action plans).

MAIN RESULTS

We included 292 studies with 678 arms; 133 (46%) had a low risk of bias, 41 (14%) unclear, and 113 (39%) had a high risk of bias. There were 26 (9%) studies conducted in low- or middle-income countries. In most studies (237, 81%), the recipients of A&F were physicians. Professional practices most commonly targeted in the studies were prescribing (138 studies, 47%) and test-ordering (103 studies, 35%). Most studies featured multifaceted interventions: the most common co-interventions were clinician education (377 study arms, 56%) and reminders (100 study arms, 15%). Forty-eight unique behaviour change techniques were identified within the study arms (mean 5.2, standard deviation 2.8, range 1 to 29). Synthesis of 558 dichotomous outcomes measuring professional practices from 177 studies testing A&F versus control revealed a median absolute improvement in desired practice of 2.7%, with an IQR of 0.0 to 8.6. Meta-analyses of these studies, accounting for multiple outcomes from the same study and weighting by effective sample size accounting for clustering, found a mean absolute increase in desired practice of 6.2% (95% confidence interval (CI) 4.1 to 8.2; moderate-certainty evidence) and an OR of 1.47 (95% CI 1.31 to 1.64; moderate-certainty evidence). Effects were similar for pre-planned subgroup analyses focused on prescribing and test-ordering outcomes. Lower baseline performance and increased number of co-interventions were both associated with larger intervention effects. Meta-regressions comparing the presence versus absence of specific A&F components to explore heterogeneity, accounting for baseline performance and number of co-interventions, suggested that A&F effects were greater with individual-recipient-level data rather than team-level data, comparing performance to top-peers or a benchmark, involving a local champion with whom the recipient had a relationship, using interactive modalities rather than just didactic or just written format, and with facilitation to support engagement, and action plans to improve performance. The meta-regressions did not find significant effects with the number of indicators in the audit, comparison to average performance of all peers, or co-development of action plans. Contrary to expectations, repeated delivery was associated with lower effect size. Direct comparisons from head-to-head trials support the use of peer-comparisons versus no comparison at all and the use of design elements in feedback that facilitate the identification and action of high-priority clinical items.

AUTHORS' CONCLUSIONS

A&F can be effective in improving professional practice, but effects vary in size. A&F is most often delivered along with co-interventions which can contribute additive effects. A&F may be most effective when designed to help recipients prioritise and take action on high-priority clinical issues and with the following characteristics: 1. targets important performance metrics where health professionals have substantial room for improvement (audit); 2. measures the individual recipient's practice, rather than their team or organisation (audit); 3. involves a local champion with an existing relationship with the recipient (feedback); 4. includes multiple, interactive modalities such as verbal and written (feedback); 5. compares performance to top peers or a benchmark (feedback); 6. facilitates engagement with the feedback (action); 7. features an actionable plan with specific advice for improvement (action). These conclusions require further confirmatory research; future research should focus on discerning ways to optimise the effectiveness of A&F interventions.

Reporting feedback on healthcare outcomes to improve quality in care: a scoping review

BACKGROUND

Providing healthcare providers (HCPs) feedback on their practice patterns and achieved outcomes is a mild to moderately effective strategy for improving healthcare quality. Best practices for providing feedback have been proposed. However, it is unknown how these strategies are implemented in practice and what their real-world effectiveness is. This scoping review addresses this gap by examining the use and reported impact of feedback reporting practices in various clinical fields.

METHODS

A systematic review of the literature was conducted, and electronic databases were searched for publications in English between 2010-June 2024. We included studies that utilized and evaluated feedback reporting to change HCP behaviours and enhance outcomes, using either qualitative or quantitative designs. Two researchers reviewed and extracted data from full texts of eligible studies, including information on study objectives, types of quality indicators, sources of data, types of feedback reporting practices, and co-interventions implemented.

RESULTS

In 279 included studies we found that most studies implemented best practices in reporting feedback, including peer comparisons (66%), active delivery of feedback (65%), timely feedback (56%), feedback specific to HCPs' practice (37%), and reporting feedback in group settings (27%). The majority (68%) combined feedback with co-interventions, such as education, post-feedback consultations, reminders, action toolboxes, social influence, and incentives. 81% showed improvement in quality indicators associated with feedback interventions. Interventions targeting outcome measures were reported as less successful than those targeting process measures, or both. Feedback interventions appeared to be more successful when supplemented with post-feedback consultations, reminders, education, and action toolboxes.

CONCLUSION

This review provides a comprehensive overview of strategies used to implement feedback interventions in a wide range of practice settings. Targeting process measures or combining them with outcome measures results in more positive outcomes. Additionally, feedback interventions may be slightly more effective when combined with other interventions designed to facilitate behaviour change. These findings can provide valuable insights for others wishing to implement similar interventions.

REGISTRATION

Open Science Framework, https://doi.org/10.17605/OSF.IO/GAJVS .

Process Evaluation Alongside a Cluster-Randomized Trial of a Multicomponent Intervention Designed to Improve Patient Access to Kidney Transplantation

Background

In a cluster-randomized trial, we learned that a novel multicomponent intervention designed to improve access to kidney transplantation did not significantly increase the rate of completed steps toward receiving a kidney transplant. Alongside the trial, we conducted a process evaluation to help interpret our findings.

Objective

To determine whether the intervention addressed targeted barriers to transplant and whether the implementation occurred as planned.

Design

Mixed-methods process evaluation informed by implementation science theories.

Setting

Chronic kidney disease (CKD) programs in Ontario, Canada. These programs, providing care to patients with advanced CKD, participated in the trial from November 1, 2017 to December 31, 2021 (either in the intervention or usual care group).

Participants

Health care providers (eg, nurses, managers) at Ontario's 27 CKD programs.

Methods

We conducted surveys (n = 114/162 [70.4%]) and semi-structured interviews (n = 17/26 [65.4%]) with providers in CKD programs in Ontario, Canada. In both the intervention-group and control-group surveys, using the Theoretical Domains Framework, we assessed perceived barriers to transplant and how barriers changed throughout the trial period. In the intervention-group surveys and interviews, using the normalization process theory, we assessed the extent to which the intervention was embedded into daily routines. In the intervention-group surveys, and by completing an implementation checklist, we assessed fidelity of implementation.

Results

Perceived barriers to transplant did not substantially differ between providers in the intervention and usual care groups, and both groups reported disagreeing or feeling neutral that the targeted barriers impeded transplant access. Intervention-group providers reported that intervention activities were becoming a regular part of their work and that they engaged with its components. However, they also felt the intervention was complex and described needing more resources, a better execution plan, and more buy-in from frontline staff. Fidelity was high for administrative support, quality improvement teams, delivery of educational resources, and patient peer support. The use of performance reports was low.

Conclusions

We identified several possible reasons why the intervention was unsuccessful. Improving access to kidney transplantation remains a high priority for health care systems. We will continue to foster a quality improvement culture, and our results will guide future interventions.

Limitations

Two of the 13 intervention-group CKD programs did not participate in this evaluation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03329521.

Facilitators and barriers to chronic non-communicable disease management under family doctor contracting services in China

Background

Chronic non-communicable diseases (NCDs) pose a significant health burden in China exacerbated by population aging and rapid urbanization. The Family Doctor Contracting Service has been implemented in China as a primary health care approach to improve NCD management and overall health outcomes. This study aims to identify factors associated with implementing chronic NCD management under the FDCS in the Chinese primary health care system.

Methods

This qualitative study was conducted in 4 purposively selected cities in China. Health administrators from the local health commission, staff members from local primary health care facilities, and community-dwelling individuals with NCDs were recruited using purposive and snowball sampling. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was adopted to inform our interview guides and data collection and analysis. Themes regarding barriers and facilitators were generated using deductive and inductive approaches.

Results

A total of 140 participants were interviewed 82 (58.6%) were female and the mean (SD) age was 51.0 (13.68) years. Significant barriers included low health literacy levels, limited awareness about NCD, insufficient healthcare professionals and medical resources, poor publicity and regulation, limited multisectoral collaboration, and inadequate audit and feedback systems. Facilitators included affordable and convenient primary health services, recognition of the indispensable benefits of NCD management, good patient-physician bonds, and the high priority given by local governments.

Conclusion

This qualitative study identified significant facilitators and barriers to the implementation of NCD management under the FDCS at the primary care level. These insights can contribute to better NCD prevention and management implementation in the Chinese primary health care system.

Utilisation of a cocreation methodology to develop claims-based indicators for feedback on implementation of comparative effectiveness research results into practice

INTRODUCTION

Comparative effectiveness research (CER) often fails to create quality improvement since implementation of CER results in clinical practice is lacking. Claims-based Audit & Feedback (A&F) provides a resource efficient tool to stimulate implementation, but it is unknown whether medical professionals accept claims-based A&F in the context of CER. Therefore, in this study, we developed claims-based indicators using a cocreation approach and evaluated medical professionals' perception regarding the validity and acceptability of these indicators.

METHODS

Between July 2019 and November 2021, we used a cocreation approach with medical experts to develop claims-based indicators for six CER trials. The aim is to use the indicators for group level feedback on implementation of CER results to medical professionals across all healthcare providers in the Netherlands. To build the indicators, we used the most recent available Dutch national healthcare-related claims data of the year 2017. The cocreation process consisted of the following steps: (1) defining the target indicator, (2) selecting relevant claims codes, (3) testing feasibility of the indicators using Dutch claims data, (4) discussing results of feasibility testing and (5) defining the final indicators and reflecting on the acceptability of the indicators for feedback on implementation of CER results by the experts.

RESULTS

Claims-based indicators could not perfectly reflect the CER population for any of the six CER trials. However, the cocreation process did lead to a final indicator that medical experts found acceptable in four of six cases. Recommendations of medical experts for improving claims-based indicators included: select patients with minimal over- or underestimation of the CER population, use proxies to identify patients, determine incidence rather than prevalence for chronic conditions and use data linkage with diagnostic test results.

CONCLUSION

A cocreation approach was a successful way to develop claims-based indicators on implementation of CER results, which were imperfect, but in some cases still acceptable as feedback to medical experts. Thus, for certain topics, claims data may provide a resource efficient data source for A&F interventions aiming to implement CER trials.

Missed opportunities: the detection and management of at-risk drinking and illicit drug use in acutely hospitalized patients

At-risk alcohol and illicit drug use are risk factors for disease and in-hospital complications. This study investigated whether clinicians document substance use in the electronic records of acutely hospitalized internal medicine patients. Alcohol and illicit drug positive patients were identified using prospectively gathered substance use data from a study sample comprising 2,872 patients included from November 2016 to December 2017 at an internal medicine hospital in Oslo, Norway. These data were unknown to hospital staff. Whether physicians recorded quantitative substance use assessments and interventions was examined in patients with study-verified alcohol use in excess of low-risk guidelines (Alcohol Use Disorder Identification Test-4 scores [AUDIT-4] of ≥5 for women and ≥7 for men) and/or illicit drug use (one or more illicit drug detected by liquid chromatography-mass spectrometry [LC-MS] analysis). Among 548 study-verified alcohol-positive patients, physicians documented quantity and frequency (QF) of use in 43.2% (n = 237) and interventions in 22.0% (n = 121). Alcohol interventions were associated with harmful drinking (AUDIT-4 ≥9 points; adjusted odds ratio [AOR] = 4.87; 95% CI: 2.54-9.31; p < 0.001) and QF assessments (AOR = 3.66; 95% CI: 1.13-11.84; p = 0.02). Among 157 illicit-positive patients, drug use was described quantitatively in 34.4% (n = 54) and interventions in 26.0% (n = 40). The rate of quantitative alcohol and illicit drug use assessment by hospital physicians is poor, with a correspondingly low intervention rate. Important opportunities for attenuating or intervening in at-risk alcohol and illicit drug use are missed.

Quality Improvement Opportunities for Better Blood Pressure Management in Pregnancy and the Postpartum Period: The Hypertension in Pregnancy Change Package

Hypertension in pregnancy, which includes both chronic hypertension and pregnancy-associated hypertension, is on the rise in the United States and is associated with an increased incidence of maternal and neonatal complications and future cardiovascular disease. Recent clinical recommendations suggest a lower blood pressure threshold for initiating treatment of chronic hypertension in pregnancy. Here we present a new quality improvement resource for outpatient clinicians to support changes to care processes for managing chronic hypertension in pregnancy and the postpartum period.

Educational interventions delivered to prescribing advisers to influence primary care prescribing: a very low-cost pragmatic randomised trial using routine data from OpenPrescribing.net

BACKGROUND

NHS England issued commissioning guidance on 18 low-priority treatments which should not be routinely prescribed in primary care. We aimed to monitor the impact of an educational intervention delivered to regional prescribing advisors by senior pharmacists from NHS England on the primary care spend on low-priority items.

METHODS

An opportunistic randomised, controlled parallel-group trial. Participants (clinical commissioning groups, CCGs) were randomised to intervention or control in a 1:1 ratio. The intervention group were invited to participate. The intervention was a one-off educational session. Our primary outcomes concerned the total prescribing of low-priority items in primary care. Secondary outcomes concerned the prescribing of specific low-priority items. We also measured the impact on information-seeking behaviour.

RESULTS

40 CCGs were randomised, 20 allocated to intervention, with 11 receiving the intervention. There was no significant impact on any prescribing outcomes. There was some possible evidence of increased engagement with data, in the form of CCG email alert sign-ups (p = 0.077). No harms were detected.

CONCLUSIONS

A one-off intervention delivered to CCGs by NHS England did not significantly influence low-priority prescribing. This trial demonstrates how routine interventions planned to improve uptake or adherence to healthcare guidance can be delivered as low-cost randomised trials and how to robustly assess their effectiveness.

TRIAL REGISTRATION

ISRCTN31218900, October 01 2018.

Audit and Feedback Interventions for Antibiotic Prescribing in Primary Care: A Systematic Review and Meta-analysis

BACKGROUND

This systematic review evaluates the effect of audit and feedback (A&F) interventions targeting antibiotic prescribing in primary care and examines factors that may explain the variation in effectiveness.

METHODS

Randomized controlled trials (RCTs) involving A&F interventions targeting antibiotic prescribing in primary care were included in the systematic review. Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and ClinicalTrials.gov were searched up to May 2024. Trial, participant, and intervention characteristics were extracted independently by 2 researchers. Random effects meta-analyses of trials that compared interventions with and without A&F were conducted for 4 outcomes: (1) total antibiotic prescribing volume; (2) unnecessary antibiotic initiation; (3) excessive prescription duration, and (4) broad-spectrum antibiotic selection. A stratified analysis was also performed based on study characteristics and A&F intervention design features for total antibiotic volume.

RESULTS

A total of 56 RCTs fit the eligibility criteria and were included in the meta-analysis. A&F was associated with an 11% relative reduction in antibiotic prescribing volume (N = 21 studies, rate ratio [RR] = 0.89; 95% confidence interval [CI]: .84, .95; I2 = 97); 23% relative reduction in unnecessary antibiotic initiation (N = 16 studies, RR = 0.77; 95% CI: .68, .87; I2 = 72); 13% relative reduction in prolonged duration of antibiotic course (N = 4 studies, RR = 0.87 95% CI: .81, .94; I2 = 86); and 17% relative reduction in broad-spectrum antibiotic selection (N = 17 studies, RR = 0.83 95% CI: .75, .93; I2 = 96).

CONCLUSIONS

A&F interventions reduce antibiotic prescribing in primary care. However, heterogeneity was substantial, outcome definitions were not standardized across the trials, and intervention fidelity was not consistently assessed. Clinical Trials Registration. Prospero (CRD42022298297).

Effectiveness of interactive dashboards to optimise prescribing in primary care: a protocol for a systematic review

Introduction

Advances in therapeutics and healthcare have led to a growing population of individuals living with multimorbidity and polypharmacy making prescribing more challenging. Most prescribing occurs in primary care and General Practitioners (GPs) have expressed interest in comparative feedback on their prescribing performance. Clinical decision support systems (CDSS) and audit and feedback interventions have shown some impact, but changes are often short-lived. Interactive dashboards, a novel approach integrating CDSS and audit and feedback elements, offer longitudinal updated data outside clinical encounters. This systematic review aims to explore the effectiveness of interactive dashboards on prescribing-related outcomes in primary care and examine the characteristics of these dashboards.

Methods

This protocol was prospectively registered on PROSPERO (CRD42023481475) and reported in line with PRISMA-P guidelines. Searches of PubMed, EMBASE, Medline, PsychINFO, CINAHL, Scopus, the Cochrane Library, and grey literature, including trial registries were performed to identify interventional studies (randomised and non-randomised) that assess the effectiveness of interactive dashboards on prescribing related outcomes. The search will be supplemented by searching references of retrieved articles with the use of an automated citation chaser. Identified records will be screened independently by two reviewers and data from eligible studies extracted using a purposely developed data extraction tool. We will narratively summarise the intervention types and those associated with improvements in prescribing outcomes. A quantitative synthesis will be carried out if a sufficient number of homogenous studies are identified. Methodological quality will be assessed by two reviewers using the Cochrane Effective Practice and Organisation of Care risk assessment tool.

Discussion

This systematic review will explore the effect of interactive dashboards on prescribing related outcome measures in primary care and describe the characteristics of interactive dashboards. This research may inform future intervention development and shape policymaking particularly in the context of ongoing and planned developments in e-prescribing infrastructure.

DEKODE-A cloud-based performance feedback model improved DKA care across multiple hospitals in the UK

AIM

A current gap in Diabetes-related ketoacidosis (DKA) research is understanding the factors contributing to variations in care and outcomes between people admitted with DKA. We aimed to create a system to facilitate gathering data on DKA management across multiple centres and identify trends in complications and outcomes associated with DKA.

RESEARCH DESIGN AND METHODS

Between January 2020 and December 2022, we set up a cloud-based Quality improvement project (QIP) that provided regular feedback to 11 hospitals in the United Kingdom (UK).

RESULTS

Of the 1977 episodes, we observed an increase in adherence in fluid prescription in hospitals C, D, E, F and G (C- 23% vs. 75% p = <0.001; D- 27% vs. 60%, p = <0.001; E- 17 vs. 79% p = <0.001; F- 16% vs. 57%, p = <0.001; G- 36% vs. 75% p = <0.001). Notable improvements in adherence to glucose monitoring were observed in hospitals B, D, and G (B- 11 vs. 38% p = <0.001; D- 36% vs. 56%, p = 0.05; G- 22% vs. 67% p = <0.001). Although we didn't observe significant changes in complications and outcomes among participating hospitals from the start to the end of the reported period, notable fluctuations were evident across quarters. These variations were relayed to the respective hospitals, underscoring how feedback and interventions could influence the care provided. This initiative also marks the initial move towards establishing and improving data collection practices in acute diabetes.

CONCLUSIONS

We demonstrate a sustainable QIP that improves adherence to national guidelines in some indicators for DKA care and serves as an early warning system to identify adverse trends.

Audit and group feedback in nursing home physician groups: lessons learned from a qualitative study

BACKGROUND

Audit and group feedback (A&F) is an instrument used to encourage healthcare professionals to improve the quality of care. Clinical practice was audited against a set of criteria and fed back to a group by a facilitator. The aim of this study was to gain a better understanding of how physician group feedback sessions in nursing homes were conducted and to what extent they resulted in action planning.

METHODS

Fifteen group feedback sessions of the antibiotic A&F program within a nursing home network were audio-recorded, transcribed, and analyzed via the Framework Method for thematic analysis. The coding was performed using the existing Calgary A&F Framework and Cooke's conceptual model of physician behaviors, and open inductive codes were added.

RESULTS

Elements of the conceptual model and the Calgary A&F Framework occurred within all group feedback sessions. The relationships within the group and with the facilitators were important elements when moving a group from interpreting the results to formulating action plans. Physician groups responded positively to the audit data, particularly if they were among the best performing. The data were met with doubt by physicians who did not recognize their own practice. When exploring potential reasons for lower guideline adherence, groups often considered data quality or external factors such as the choice of non-adherent treatment by locum staff. The degree of reflection on personal factors as explanations for low adherence and the extent to which groups identified learning and improvement opportunities varied: some groups were able to formulate action plans to address data problems and knowledge gaps, whereas others scheduled a follow-up meeting to develop action plans for treatment or prescribing practice changes.

CONCLUSIONS

The facilitator was crucial in supporting the group in interpreting the results, steering the conversation towards sharing change cues, and helping the physician group in developing action plans. The degree of reflection and action planning varied by group. By implementing the lessons learned from this study, group feedback sessions can be refined, supporting participants in action planning.

Understanding "Alert Fatigue" in Primary Care: Qualitative Systematic Review of General Practitioners Attitudes and Experiences of Clinical Alerts, Prompts, and Reminders

BACKGROUND

The consistency and quality of care in modern primary care are supported by various clinical reminders (CRs), which include "alerts" describing the consequences of certain decisions and "prompts" that remind users to perform tasks promoting desirable clinical behaviors. However, not all CRs are acted upon, and many are disregarded by general practitioners (GPs), a chronic issue commonly referred to as "alert fatigue." This phenomenon has significant implications for the safety and quality of care, GP burnout, and broader medicolegal consequences. Research on mitigating alert fatigue and optimizing the use of CRs remains limited. This review offers much-needed insight into GP attitudes toward the deployment, design, and overall effectiveness of CRs.

OBJECTIVE

This systematic review aims to synthesize current qualitative research on GPs' attitudes toward CRs, enabling an exploration of the interacting influences on the occurrence of alert fatigue in GPs, including the deployment, design, and perceived efficacy of CRs.

METHODS

A systematic literature search was conducted across the Health Technology Assessment database, MEDLINE, MEDLINE In-Process, Embase, CINAHL, Conference Proceedings Citation Index, PsycINFO, and OpenGrey. The search focused on primary qualitative and mixed methods research conducted in general or family practice, specifically exploring GPs' experiences with CRs. All databases were searched from inception to December 31, 2023. To ensure structured and practicable findings, we used a directed content analysis of the data, guided by the 7 domains of the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, including domains related to Technology, Adopter attitudes, and Organization.

RESULTS

A total of 9 studies were included, and the findings were organized within the 7 domains. Regarding Condition and Value Proposition, GPs viewed CRs as an effective way to maintain or improve the safety and quality of care they provide. When considering the attributes of the Technology, the efficacy of CRs was linked to their frequency, presentation, and the accuracy of their content. Within Adopters, concerns were raised about the accuracy of CRs and the risk that their use could diminish the value of GP experience and contextual understanding. From an Organization perspective, the need for training on the use and benefits of CRs was highlighted. Finally, in the context of the Wider system and their Embedding Over Time, suggestions included sharing best practices for CR use and involving GPs in their design.

CONCLUSIONS

While GPs acknowledged that CRs, when used optimally, can enhance patient safety and quality of care, several concerns emerged regarding their design, content accuracy, and lack of contextual nuance. Suggestions to improve CR adherence included providing coherent training, enhancing their design, and incorporating more personalized content.

TRIAL REGISTRATION

PROSPERO CRD42016029418; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=29418.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13643-017-0627-z.

Variation Between Hospitals in Outcomes and Costs of IBD Care: Results From the IBD Value Study

BACKGROUND

Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals.

METHODS

We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital were analyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models.

RESULTS

We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations.

CONCLUSIONS

Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care.

TRIAL REGISTRATION NUMBER

NL8276.

Effectiveness of Electronic Quality Improvement Activities to Reduce Cardiovascular Disease Risk in People With Chronic Kidney Disease in General Practice: Cluster Randomized Trial With Active Control

BACKGROUND

Future Health Today (FHT) is a program integrated with electronic medical record (EMR) systems in general practice and comprises (1) a practice dashboard to identify people at risk of, or with, chronic disease who may benefit from intervention; (2) active clinical decision support (CDS) at the point of care; and (3) quality improvement activities. One module within FHT aims to facilitate cardiovascular disease (CVD) risk reduction in people with chronic kidney disease (CKD) through the recommendation of angiotensin-converting enzyme inhibitor inhibitors (ACEI), angiotensin receptor blockers (ARB), or statins according to Australian guidelines (defined as appropriate pharmacological therapy).

OBJECTIVE

This study aimed to determine if the FHT program increases the proportion of general practice patients with CKD receiving appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) to reduce CVD risk at 12 months postrandomization compared with active control (primary outcome).

METHODS

General practices recruited through practice-based research networks in Victoria and Tasmania were randomly allocated 1:1 to the FHT CKD module or active control. The intervention was delivered to practices between October 4, 2021, and September 30, 2022. Data extracted from EMRs for eligible patients identified at baseline were used to evaluate the trial outcomes at the completion of the intervention period. The primary analysis used an intention-to-treat approach. The intervention effect for the primary outcome was estimated with a marginal logistic model using generalized estimating equations with robust SE.

RESULTS

Overall, of the 734 eligible patients from 19 intervention practices and 715 from 21 control practices, 82 (11.2%) and 70 (9.8%), respectively, had received appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) at 12 months postintervention to reduce CVD risk, with an estimated between-trial group difference (Diff) of 2.0% (95% CI -1.6% to 5.7%) and odds ratio of 1.24 (95% CI 0.85 to 1.81; P=.26). Of the 470 intervention patients and 425 control patients that received a recommendation for statins, 61 (13%) and 38 (9%) were prescribed statins at follow-up (Diff 4.3%, 95% CI 0 to 8.6%; odds ratio 1.55, 95% CI 1.02 to 2.35; P=.04). There was no statistical evidence to support between-group differences in other secondary outcomes and general practice health care use.

CONCLUSIONS

FHT harnesses the data stored within EMRs to translate guidelines into practice through quality improvement activities and active clinical decision support. In this instance, it did not result in a difference in prescribing or clinical outcomes except for small changes in statin prescribing. This may relate to COVID-19-related disruptions, technical implementation challenges, and recruiting higher performing practices to the trial. A separate process evaluation will further explore factors impacting implementation and engagement with FHT.

TRIAL REGISTRATION

ACTRN12620000993998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380119.

Knowledge Translation Interventions to Address Gaps in Rectal Cancer Care

Importance

Over the last 2 decades, increasing use of multimodal strategies has led to significant improvements in oncologic outcomes for patients with rectal cancer. However, uptake of these strategies varies among centers, suggesting that best evidence is not always implemented into practice.

Objectives

To identify gaps in care and initiate knowledge translation interventions to close existing gaps.

Design, Setting, and Participants

This 3-year multifaceted, prospective quality improvement study was conducted at 8 high-volume rectal cancer centers across Canada. From April 2016 to December 2018, patients with stage I to III rectal cancer undergoing total mesorectal excision were enrolled. Data were analyzed from January 2022 through December 2023.

Interventions

Process measures for multimodal strategies to optimize rectal cancer care were selected and prospectively collected for patients with stage I to III rectal cancer undergoing total mesorectal excision. Knowledge translation interventions were implemented to increase uptake of these strategies.

Main Outcome and Measure

Change in uptake of process measures over the study period, with measures taken every 3 months, from time 1 (baseline) to time 7 (18 months).

Results

Among 645 patients with stage I to III rectal cancer (389 male [60.3%]; mean [SD] age, 68.1 [8.2] years), iterative results showed that uptake of 6 of 12 process measures (eg, presentation at multidisciplinary cancer conference: 22 of 77 patients [28.6%] at time 1 to 64 of 91 patients [70.3%] at time 7; P < .001) and 1 pathology measure (inadequate lymph node retrieval: 15 of 77 patients at time 1 [19.5%] to 6 of 91 patients at time 7 [6.6%]; P = .002) improved over time. Positive circumferential resection margin, positive distal margin, and inadequate lymph node retrieval rates at 2 years were 44 patients (6.8%), 10 patients (1.6%), and 79 patients (12.2%), respectively.

Conclusions and Relevance

In this study, there was an improvement in 6 process measures and 1 pathology measure for patients with stage I to III rectal cancer. Furthermore, this study led to standardized processes of care for rectal cancer that may facilitate continuous quality improvement and multicenter trials across Canada.

The Centre for Evidence-Based Orthopaedics Tool for the Implementation of Evidence-Based Practice

Introduction Updating practices can be challenging in evidence-based practice when integrating the evidence, clinical expertise, and patient values and preferences. Implementing evidence-based practice requires individual, collective, and organizational behavioral changes. Effective behavior change interventions are necessary to facilitate the implementation of new evidence. We propose a tool to facilitate the implementation of evidence in clinical decision-making by changing healthcare providers' behaviors. Methods The Centre for Evidence-Based Orthopaedics (CEBO) tool was developed to bridge the gap between evidence and practice in a hospital department. The development process follows a Plan-Do-Study-Act (PDSA) structure and is based on the COM-B model (Capability, Opportunity, Motivation, Behavior) and the Theoretical Domains Framework (TDF), which recognize that effective behavior change necessitates addressing factors at both individual and organizational levels. The CEBO tool consists of four phases, guiding the process from identifying an evidence-practice gap to evaluating behavioral changes following implementation. Results We applied the CEBO tool to two surgical cases, which led to substantial behavioral changes in orthopedic surgeons' treatment choices. Our findings indicate that the CEBO tool is feasible and can influence surgeons' behaviors to align more closely with the best available evidence. Conclusion The CEBO tool helps align practice with the best available evidence. Although implementing new practices effectively is time-consuming, it seems achievable with the CEBO tool. Substantial behavioral changes were observed among surgeons in both cases.

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

Importance

Efficient care processes are crucial to minimize treatment delays and improve outcome after endovascular thrombectomy (EVT) in patients with ischemic stroke. A potential means to improve care processes is performance feedback.

Objective

To evaluate the effect of performance feedback to hospitals on treatment times for EVT.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from January 1, 2020, to June 30, 2022. Participants were consecutive adult patients with ischemic stroke who underwent EVT in 13 Dutch hospitals. No patients were excluded. Data analysis took place from March to May 2023.

Intervention

The intervention consisted of feedback on hospital performance using structure, process, and outcome indicators. Indicator scores were based on data from a national quality registry and compared with a benchmark. Performance feedback was provided through a dashboard for local quality improvement teams who developed and implemented improvement plans based on the feedback. Every 6 months, 3 to 4 randomly selected hospitals switched to the intervention condition.

Main Outcome and Measures

The primary outcome was time from door to groin puncture for all patients treated with EVT. Secondary outcomes included door-to-needle time, National Institutes of Health Stroke Scale (NIHSS) score at day 2, expanded Treatment in Cerebral Infarction (eTICI) score, and modified Rankin Scale (mRS) score at 3 months. The effect of the intervention was estimated with multivariable linear mixed models.

Results

A total of 4747 patients were included (intervention: 2431; control: 2316). Their mean (SD) age was 72 (13) years; 2337 (49.2%) were female and 2410 (50.8%) were male. The median (IQR) baseline NIHSS score was 14 (8-19). Median (IQR) door-to-groin puncture time under the intervention condition was 47 (25-71) minutes, compared with 52 (29-75) minutes under the control condition. The adjusted absolute reduction was 5 minutes (β = -4.8; 95% CI, -9.5 to -0.1; P = .04), corresponding to a relative reduction of 9.2% (95% CI, -18.3% to -0.2%).

Conclusion and Relevance

This study found that performance feedback provided through a dashboard used by local quality improvement teams reduced door-to-groin puncture time for EVT. Implementation of performance feedback in hospitals providing EVT can improve the quality of care for ischemic stroke.

Trial Registration

The Netherlands Trial Register: NL9090.

Study protocol: type II hybrid effectiveness-implementation study of routine functional status screening in VA primary care

BACKGROUND

Maintaining functional status, defined as the ability to perform daily activities such as bathing, dressing, and preparing meals, is central to older adults' quality of life, health, and ability to remain independent. Identifying functional impairments - defined as having difficulty or needing help performing these activities - is essential for clinicians to provide optimal care to older adults, and on a population level, understanding function can help anticipate service needs. Yet uptake of standardized measurement of functional status into routine patient care has been slow and inconsistent due to the burden posed by current tools. The goal of the Patient-Aligned Care Team (PACT) Functional Status Screening Initiative is to implement and evaluate a patient-centered, low-burden intervention to improve identification and management of functional impairment among older veterans in Veterans Health Administration (VHA) primary care settings.

METHODS

We will conduct a hybrid type 2 implementation-effectiveness cluster-randomized adaptive trial at 8 VHA sites using the Practical, Robust Implementation and Sustainability Model (PRISM) to guide implementation and evaluation. During a Pre-Implementation phase, we will engage clinical partners and develop local adaptations to maximize intervention-setting fit. During an Implementation phase, we will launch a standard bundle of implementation strategies (coalition building, champions, technical assistance) and system-level audit and feedback, identify sites with low uptake, and randomize those sites to receive continued standard vs. enhanced strategies (standard strategies plus clinician-level audit and feedback). The primary implementation outcome is reach (proportion of eligible patients at each site who receive screening/assessment) and the primary effectiveness outcome is appropriate management of impairment (proportion of patients with identified impairments who receive related referrals).

DISCUSSION

Implementing routine measurement of functional status in primary care has the potential to improve identification and management of functional impairment for older veterans. Improved management includes increasing access to services and supports for veterans and family caregivers, reducing potentially preventable acute care utilization, and allowing veterans to live in the least restrictive setting for as long as possible. Implementation will also provide data to inform the delivery of proactive interventions to prevent and delay development of functional impairment and improve quality of life, health, and independence.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov on May 7, 2024, at NCT06404970 ( https://clinicaltrials.gov/ ).

REPORTING GUIDELINES

Standards for Reporting Implementation Studies (Additional file 1).

Mixed Comparative Evaluation of a Training Program Dedicated to Cystic Fibrosis Reference Centers: Protocol for the Pilot Implementation of Shared Decision-Making in the Treatment of Diabetes in Adult Patients With Cystic Fibrosis

BACKGROUND

Diabetes affects half of the patients with cystic fibrosis who are aged 30 years and older. Diabetes progresses asymptomatically over a long period of time. Two treatment options are possible: start insulin as soon as cystic fibrosis diagnosis is made with the additional constraints of cystic fibrosis or wait while monitoring the patient's clinical condition and start insulin when diabetes symptoms develop and therefore later. This situation is particularly well suited to shared decision-making (SDM) between the physician (health care team) and patient/relatives.

OBJECTIVE

The aim of this study was to perform qualitative and quantitative analyses for evaluating the outcomes and experience of SDM implementation between the physician/health care team trained for SDM and patients/their relatives for cystic fibrosis-related diabetes.

METHODS

A quasi-experimental with a comparison study will be developed. Three cystic fibrosis reference centers (CFRCs) will be trained in SDM by using a web-based training, including a validated decision aid and coaching for physicians and the medical team. Two control CFRCs will maintain their usual practices. A qualitative analysis through observation of consultations, individual semistructured interviews with patients, and focus groups in CFRCs will be conducted based on a thematic content analysis. Questionnaires related to decision-making and experience of decision-making with and without SDM implementation will be administered to patients and physicians.

RESULTS

Forty patients will be included (8 patients in each center), that is, 60 consultation observations (2 consultations per patient in the intervention groups given the modalities of the SDM process) will be conducted in 2025. Eight focus groups will be conducted in the 5 centers (2 groups in each intervention CFRC and 1 group in each control CFRC). This qualitative corpus plus responses to the patient and physician questionnaires will make it possible to know whether the practice of SDM in CFRCs is increased by an implementation strategy and to analyze the experience of patients and their relatives regarding decision-making modalities. Analysis of the outcomes and experience of the implementation of SDM are of importance to identify the facilitators and barriers to SDM from patients' and CFRCs' point of views.

CONCLUSIONS

Our study will give us keys to adapt, improve, and disseminate SDM more widely in the context of cystic fibrosis therapy. SDM could thus be used in routine clinical practice in CFRCs at the national level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04891159; https://clinicaltrials.gov/study/NCT04891159?id=NCT04891159.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/62931.

Peer Audit and Feedback: A Documentation-Focused Quality Improvement Project

BACKGROUND AND OBJECTIVES

Nurses' documentation of communication, including notification of critical laboratory results (CLR), is important to ensure safe, high-quality care. Evidence supports peer audit with feedback as a quality improvement (QI) intervention to improve documentation. Nursing compliance with CLR documentation requirements was below goal for several years in an intensive care unit. To address this problem, a peer audit and feedback intervention was implemented and evaluated.

METHODS

Compliance with CLR documentation requirements was evaluated pre- and postintervention, for a total of 12 months. The evaluation also included data from the peer audits and a survey to assess nurses' perceptions. The 5-month intervention was a timely peer audit and feedback of CLR events.

RESULTS

CLR documentation compliance improved from 6.4% to 9.6% (50% improvement), which was clinically meaningful but not statistically significant. Nurses had overall positive perceptions of the peer audit and feedback as a QI tool, perceiving it as nonpunitive and helpful for improving practice.

CONCLUSION

Results support continued examination of peer audit and feedback to improve nursing documentation. Future projects should address the limited time for nurses to engage in QI projects.