Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
Implement Sci. 2022 May 26;17(1):34. doi: 10.1186/s13012-022-01208-5.
Audit and feedback aims to improve patient care by comparing healthcare performance against explicit standards. It is used to monitor and improve patient care, including through National Clinical Audit (NCA) programmes in the UK. Variability in effectiveness of audit and feedback is attributed to intervention design; separate randomised trials to address multiple questions about how to optimise effectiveness would be inefficient. We evaluated different feedback modifications to identify leading candidates for further "real-world" evaluation.
Using an online fractional factorial screening experiment, we randomised recipients of feedback from five UK NCAs to different combinations of six feedback modifications applied within an audit report excerpt: use effective comparators, provide multimodal feedback, recommend specific actions, provide optional detail, incorporate the patient voice, and minimise cognitive load. Outcomes, assessed immediately after exposure to the online modifications, included intention to enact audit standards (primary outcome, ranked on a scale of -3 to +3, tailored to the NCA), comprehension, user experience, and engagement.
We randomised 1241 participants (clinicians, managers, and audit staff) between April and October 2019. Inappropriate repeated participant completion occurred; we conservatively excluded participant entries during the relevant period, leaving a primary analysis population of 638 (51.4%) participants. None of the six feedback modifications had an independent effect on intention across the five NCAs. We observed both synergistic and antagonistic effects across outcomes when modifications were combined; the specific NCA and whether recipients had a clinical role had dominant influences on outcome, and there was an antagonistic interaction between multimodal feedback and optional detail. Among clinical participants, predicted intention ranged from 1.22 (95% confidence interval 0.72, 1.72) for the least effective combination in which multimodal feedback, optional detail, and reduced cognitive load were applied within the audit report, up to 2.40 (95% CI 1.88, 2.93) for the most effective combination including multimodal feedback, specific actions, patient voice, and reduced cognitive load.
Potentially important synergistic and antagonistic effects were identified across combinations of feedback modifications, audit programmes, and recipients, suggesting that feedback designers must explicitly consider how different features of feedback may interact to achieve (or undermine) the desired effects.
International Standard Randomised Controlled Trial Number: ISRCTN41584028.
审核和反馈旨在通过将医疗保健绩效与明确标准进行比较来改善患者护理。它用于监测和改善患者护理，包括通过英国国家临床审核 (NCA) 计划。审核和反馈效果的差异归因于干预设计；单独进行针对如何优化效果的多个问题的随机对照试验将是低效的。我们评估了不同的反馈修改，以确定进一步“真实世界”评估的主要候选者。
我们使用在线分数阶析因筛选实验，将来自五个英国 NCA 的反馈接收者随机分配到审核报告摘录中应用的六种反馈修改的不同组合中：使用有效的对照、提供多模式反馈、推荐具体行动、提供可选详细信息、纳入患者声音和最小化认知负担。在暴露于在线修改后立即评估的结果包括实施审核标准的意图（主要结果，根据 NCA 进行了调整，排名从-3 到+3）、理解、用户体验和参与度。
我们在 2019 年 4 月至 10 月期间随机分配了 1241 名参与者（临床医生、经理和审核人员）。参与者不恰当地重复完成；我们保守地排除了相关期间的参与者条目，留下了一个主要分析人群，由 638 名（51.4%）参与者组成。在五个 NCA 中，六种反馈修改都没有对意图产生独立影响。当修改组合在一起时，我们观察到协同和拮抗作用都存在；具体的 NCA 和收件人是否具有临床角色对结果有主导影响，并且多模式反馈和可选详细信息之间存在拮抗相互作用。在临床参与者中，预测的意图范围从审核报告中应用多模式反馈、可选详细信息和降低认知负担的最无效组合中的 1.22（95%置信区间 0.72, 1.72）到包括多模式反馈、具体行动、患者声音和降低认知负担的最有效组合中的 2.40（95%置信区间 1.88, 2.93）。
在反馈修改、审核计划和收件人的组合中发现了潜在的重要协同和拮抗作用，这表明反馈设计者必须明确考虑不同反馈功能如何相互作用以实现（或破坏）预期效果。
国际标准随机对照试验编号：ISRCTN41584028。
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