Ivers Noah, Jamtvedt Gro, Flottorp Signe, Young Jane M, Odgaard-Jensen Jan, French Simon D, O'Brien Mary Ann, Johansen Marit, Grimshaw Jeremy, Oxman Andrew D
Department of Family Medicine, Women’s College Hospital, Toronto, Canada. 2Norwegian Knowledge Centre for the Health Services,Oslo,
Cochrane Database Syst Rev. 2012 Jun 13;2012(6):CD000259. doi: 10.1002/14651858.CD000259.pub3.
Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.
To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).
Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.
All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.
We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.
AUTHORS' CONCLUSIONS: Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.
审核与反馈作为一种改善专业实践的策略被广泛应用，它既可以单独使用，也可以作为多方面质量改进干预措施的一个组成部分。这基于这样一种信念，即当医疗保健专业人员收到表明其临床实践与理想目标不一致的绩效反馈时，他们会被促使改变自己的实践。尽管审核与反馈作为一种质量改进策略很普遍，但关于审核与反馈在改善医疗保健实践方面的有效性以及导致更大影响的审核与反馈的特征，仍存在不确定性。
评估审核与反馈对医疗保健专业人员的实践和患者结局的影响，并研究可能解释审核与反馈有效性差异的因素。
我们检索了《Cochrane系统评价数据库》2010年第4期，Cochrane图书馆的一部分。www.thecochranelibrary.com，包括Cochrane有效实践与护理组织（EPOC）小组专业注册库（检索于2010年12月10日）；MEDLINE，Ovid（1950年至2010年第11周第3期）（检索于2010年12月9日）；EMBASE，Ovid（1980年至2010年第48周）（检索于2010年12月9日）；CINAHL，Ebsco（1981年至今）（检索于2010年12月10日）；科学引文索引和社会科学引文索引，ISI Web of Science（1975年至今）（检索于2011年9月12 - 15日）。
审核与反馈（定义为特定时间段内临床绩效的总结）的随机试验，这些试验报告了客观测量的卫生专业人员实践或患者结局。对于多方面干预措施，仅纳入将审核与反馈视为至少一个干预组核心、关键方面的试验。
所有数据由两位独立的综述作者提取。对于每项研究的主要结局，我们计算了二分结局中符合期望实践依从性的中位数绝对风险差（RD）（根据基线表现进行调整），以及连续结局相对于对照组的中位数百分比变化。在各项研究中，中位数效应大小根据参与每项研究的卫生专业人员数量进行加权。我们研究了以下因素，作为不同比较中干预有效性差异的可能解释：反馈形式、反馈来源、反馈频率、改进指导、所需改变方向、基线表现、接受者职业以及试验本身的偏倚风险。我们还进行了探索性分析，以评估背景和目标临床行为的作用。进行了定量（元回归）、可视化和定性分析，以检查与这些因素相关的效应大小差异。
我们纳入并分析了140项研究用于本综述。在主要分析中，来自70项研究的总共108个比较将审核与反馈作为核心、关键组成部分的任何干预与常规护理进行了比较，并评估了对专业实践的影响。在排除高偏倚风险的研究后，来自49项研究的82个比较呈现二分结局，加权中位数调整后的RD为医疗保健专业人员对期望实践的依从性绝对增加4.3%（四分位间距（IQR）0.5%至16%）。在来自21项研究的26个连续结局比较中，相对于对照组的加权中位数调整百分比变化为1.3%（IQR = 1.3%至28.9%）。对于患者结局，来自6项报告二分结局研究的12个比较的加权中位数RD为 - 0.4%（IQR - 1.3%至1.6%），来自5项报告连续结局研究的8个比较的加权中位数百分比变化为17%（IQR 1.5%至17%）。多变量元回归表明，当基线表现较低、来源是上级或同事、反馈不止提供一次、以口头和书面形式提供且包括明确目标和行动计划时，反馈可能更有效。此外，效应大小因干预针对的临床行为而异。
审核与反馈通常会在专业实践中带来虽小但可能重要的改善。审核与反馈的有效性似乎取决于基线表现以及反馈的提供方式。未来关于审核与反馈的研究应直接比较提供反馈的不同方式。
