Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Room L1202, Box 711, Ottawa, ON, K1H 8L6, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.
Implement Sci. 2023 May 10;18(1):13. doi: 10.1186/s13012-023-01271-6.
While audit & feedback (A&F) is an effective implementation intervention, the design elements which maximize effectiveness are unclear. Partnering with a healthcare quality advisory organization already delivering feedback, we conducted a pragmatic, 2 × 2 factorial, cluster-randomized trial to test the impact of variations in two factors: (A) the benchmark used for comparison and (B) information framing. An embedded process evaluation explored hypothesized mechanisms of effect.
Eligible physicians worked in nursing homes in Ontario, Canada, and had voluntarily signed up to receive the report. Groups of nursing homes sharing physicians were randomized to (A) physicians' individual prescribing rates compared to top-performing peers (the top quartile) or the provincial median and (B) risk-framed information (reporting the number of patients prescribed high-risk medication) or benefit-framed information (reporting the number of patients not prescribed). We hypothesized that the top quartile comparator and risk-framing would lead to greater practice improvements. The primary outcome was the mean number of central nervous system-active medications per resident per month. Primary analyses compared the four arms at 6 months post-intervention. Factorial analyses were secondary. The process evaluation comprised a follow-up questionnaire and semi-structured interviews.
Two hundred sixty-seven physicians (152 clusters) were randomized: 67 to arm 1 (median benchmark, benefit framing), 65 to arm 2 (top quartile benchmark, benefit framing), 75 to arm 3 (median benchmark, risk framing), and 60 to arm 4 (top quartile benchmark, risk framing). There were no significant differences in the primary outcome across arms or for each factor. However, engagement was low (27-31% of physicians across arms downloaded the report). The process evaluation indicated that both factors minimally impacted the proposed mechanisms. However, risk-framed feedback was perceived as more actionable and more compatible with current workflows, whilst a higher target might encourage behaviour change when physicians identified with the comparator.
Risk framing and a top quartile comparator have the potential to achieve change. Further work to establish the strategies most likely to enhance A&F engagement, particularly with physicians who may be most likely to benefit from feedback, is required to support meaningfully addressing intricate research questions concerning the design of A&F.
ClinicalTrials.gov, NCT02979964 . Registered 29 November 2016.
审核与反馈（A&F）是一种有效的实施干预措施，但最大化其效果的设计要素尚不清楚。我们与一家已经提供反馈的医疗保健质量咨询组织合作，进行了一项实用的、2×2 析因、集群随机试验，以测试两种因素变化的影响：（A）用于比较的基准和（B）信息框架。一项嵌入式过程评估探讨了假设的影响机制。
合格的医生在加拿大安大略省的养老院工作，并自愿签署报告。共享医生的养老院小组被随机分配到（A）医生的个人处方率与表现最好的同行（前四分之一）或省级中位数进行比较，或与（B）风险框架信息（报告开处高风险药物的患者数量）或效益框架信息（报告未开处高风险药物的患者数量）进行比较。我们假设四分位比较器和风险框架将导致更大的实践改进。主要结果是每位居民每月的中枢神经系统活性药物的平均数量。主要分析比较了干预后 6 个月的四个组。析因分析是次要的。过程评估包括后续问卷和半结构化访谈。
267 名医生（152 个集群）被随机分配：67 名进入第 1 组（中位数基准，效益框架），65 名进入第 2 组（四分位比较器基准，效益框架），75 名进入第 3 组（中位数基准，风险框架），60 名进入第 4 组（四分位比较器基准，风险框架）。各组之间或每个因素之间的主要结果均无显著差异。然而，参与度很低（各组有 27-31%的医生下载了报告）。过程评估表明，这两个因素对拟议机制的影响都很小。然而，风险框架反馈被认为更具可操作性，更符合当前的工作流程，而当医生认同比较器时，更高的目标可能会鼓励行为改变。
风险框架和四分位比较器有可能实现变革。需要进一步开展工作，以确定最有可能增强审核与反馈参与度的策略，特别是针对那些最有可能从反馈中受益的医生，以支持解决关于审核与反馈设计的复杂研究问题。
ClinicalTrials.gov，NCT02979964。于 2016 年 11 月 29 日注册。
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