Doris Tove Kristoffersen

Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback

Background: Many people advocate audit and feedback as a strategy for improving professional practice. The main results of an update of a Cochrane review on the effects of audit and feedback are reported. Data sources: The Cochrane Effective Practice and Organisation of Care Group’s register up to January 2004 was searched. Randomised trials of audit and feedback that reported objectively measured professional practice in a healthcare setting or healthcare outcomes were included. Review methods: Data were independently extracted and the quality of studies were assessed by two reviewers. Quantitative, visual and qualitative analyses were undertaken. Main results: 118 trials are included in the review. In the primary analysis, 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback was a component to no intervention. For dichotomous outcomes, the median-adjusted risk difference of compliance with desired practice was 5% (interquartile range 3–11). For continuous outcomes, the median-adjusted percentage change relative to control was 16% (interquartile range 5–37). Low baseline compliance with recommended practice and higher intensity of audit and feedback appeared to predict the effectiveness of audit and feedback. Conclusions: Audit and feedback can be effective in improving professional practice. The effects are generally small to moderate. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.

Systematic review to determine whether participation in a trial influences outcome

Abstract Objective To systematically compare the outcomes of participants in randomised controlled trials (RCTs) with those in comparable non-participants who received the same or similar treatment. Table 1 Summary of studies included in sensitivity analysis Number of comparisons Number of similar results Number better in RCT Number worse in RCT Selection bias: Low risk 6 6 — — No imbalance 22 19 1 2 Adjusted results 12 7 4 2 Partially controlled 18 15 2 1 Poorly controlled 33 30 3 — Detection bias: Low risk* 78 66 8 3 Partially met, similarly measured 5 3 2 1 High risk 8 8 — — Exclusion bias: No losses to follow up 38 32 4 2 1 person to 20% lost to follow up 33 30 2 1 > 20% loss to follow up 11 10 — 1 Unclear 9 4 4 1 Reasons for non-participation: Refused 27 18 7 2 Refused because of preference 23 20 1 2 RCT versus preference trial 16 15 — 1 Not invited 8 8 — — Treated by non-participating clinicians 1 1 — — Different skills required for treatment: Surgery and procedures 28 25 1 2 Drug treatment 22 17 4 1 Radiology 14 12 1 1 Usual care 9 8 1 — Counselling and education 8 8 — — Watchful waiting 7 6 — 1 Different clinical area: Oncology 28 23 3 2 Obstetrics and gynaecology 14 12 2 1 Cardiology 13 10 2 1 Other internal medicine 11 9 2 — Psychology and drug misuse 9 9 — — Paediatrics 8 7 — 1 Respiration 2 2 — — RCT=randomised controlled trial. * Outcomes were measured in same way. Data sources Bibliographic databases, reference lists from eligible articles, medical journals, and study authors. Review methods RCTs and cohort studies that evaluated the clinical outcomes of participants in RCTs and comparable non-participants who received the same or similar treatment. Results Five RCTs (six comparisons) and 50 cohort studies (85 comparisons) provided data on 31 140 patients treated in RCTs and 20 380 comparable patients treated outside RCTs. In the five RCTs, in which patients were given the option of participating or not, the comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions considered. 73 dichotomous outcomes were compared, of which 59 reported no statistically significant differences. For patients treated within RCTs, 10 comparisons reported significantly better outcomes and four reported significantly worse outcomes. Significantly heterogeneity was found (I2 = 89%) among the comparisons of 73 dichotomous outcomes; none of our a priori explanatory factors helped explain this heterogeneity. The 18 comparisons of continuous outcomes showed no significant differences in heterogeneity (I2 = 0%). The overall pooled estimate for continuous outcomes of the effect of participating in an RCT was not significant (standardised mean difference 0.01, 95% confidence interval −0.10 to 0.12). Conclusion No strong evidence was found of a harmful or beneficial effect of participating in RCTs compared with receiving the same or similar treatment outside such trials.

Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention

Background A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease. Methods and Findings We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49–2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals. Conclusions Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.

The Effect of Alternative Summary Statistics for Communicating Risk Reduction on Decisions about Taking Statins: A Randomized Trial

Carling and colleagues carry out a trial evaluating different methods of communicating information to people regarding the risks and benefits of taking statins. They suggest that natural frequencies are likely to be the most appropriate summary statistic for presenting the effects of treatment.

Comparing hospital mortality – how to count does matter for patients hospitalized for acute myocardial infarction (AMI), stroke and hip fracture

BackgroundMortality is a widely used, but often criticised, quality indicator for hospitals. In many countries, mortality is calculated from in-hospital deaths, due to limited access to follow-up data on patients transferred between hospitals and on discharged patients. The objectives were to: i) summarize time, place and cause of death for first time acute myocardial infarction (AMI), stroke and hip fracture, ii) compare case-mix adjusted 30-day mortality measures based on in-hospital deaths and in-and-out-of hospital deaths, with and without patients transferred to other hospitals.MethodsNorwegian hospital data within a 5-year period were merged with information from official registers. Mortality based on in-and-out-of-hospital deaths, weighted according to length of stay at each hospital for transferred patients (W30D), was compared to a) mortality based on in-and-out-of-hospital deaths excluding patients treated at two or more hospitals (S30D), and b) mortality based on in-hospital deaths (IH30D). Adjusted mortalities were estimated by logistic regression which, in addition to hospital, included age, sex and stage of disease. The hospitals were assigned outlier status according to the Z-values for hospitals in the models; low mortality: Z-values below the 5-percentile, high mortality: Z-values above the 95-percentile, medium mortality: remaining hospitals.ResultsThe data included 48 048 AMI patients, 47 854 stroke patients and 40 142 hip fracture patients from 55, 59 and 58 hospitals, respectively. The overall relative frequencies of deaths within 30 days were 19.1% (AMI), 17.6% (stroke) and 7.8% (hip fracture). The cause of death diagnoses included the referral diagnosis for 73.8-89.6% of the deaths within 30 days. When comparing S30D versus W30D outlier status changed for 14.6% (AMI), 15.3% (stroke) and 36.2% (hip fracture) of the hospitals. For IH30D compared to W30D outlier status changed for 18.2% (AMI), 25.4% (stroke) and 27.6% (hip fracture) of the hospitals.ConclusionsMortality measures based on in-hospital deaths alone, or measures excluding admissions for transferred patients, can be misleading as indicators of hospital performance. We propose to attribute the outcome to all hospitals by fraction of time spent in each hospital for patients transferred between hospitals to reduce bias due to double counting or exclusion of hospital stays.

The Effect of Alternative Graphical Displays Used to Present the Benefits of Antibiotics for Sore Throat on Decisions about Whether to Seek Treatment: A Randomized Trial

In a randomized trial, Cheryl Carling and colleagues evaluate how people respond to different statistical presentations regarding the consequences of taking antibiotic treatment for sore throat.

The effects of mandatory prescribing of thiazides for newly treated, uncomplicated hypertension : interrupted time-series analysis

Background The purpose of our study was to evaluate the effects of a new reimbursement rule for antihypertensive medication that made thiazides mandatory first-line drugs for newly treated, uncomplicated hypertension. The objective of the new regulation was to reduce drug expenditures. Methods and Findings We conducted an interrupted time-series analysis on prescribing data before and after the new reimbursement rule for antihypertensive medication was put into effect. All patients started on antihypertensive medication in 61 general practices in Norway were included in the analysis. The new rule was put forward by the Ministry of Health and was approved by parliament. Adherence to the rule was monitored only minimally, and there were no penalties for non-adherence. Our primary outcome was the proportion of thiazide prescriptions among all prescriptions made for persons started on antihypertensive medication. Secondary outcomes included the proportion of patients who, within 4 mo, reached recommended blood-pressure goals and the proportion of patients who, within 4 mo, were not started on a second antihypertensive drug. We also compared drug costs before and after the intervention. During the baseline period, 10% of patients started on antihypertensive medication were given a thiazide prescription. This proportion rose steadily during the transition period, after which it remained stable at 25%. For other outcomes, no statistically significant differences were demonstrated. Achievement of treatment goals was slightly higher (56.6% versus 58.4%) after the new rule was introduced, and the prescribing of a second drug was slightly lower (24.0% versus 21.8%). Drug costs were reduced by an estimated Norwegian kroner 4.8 million (€0.58 million, US

Survival curves to support quality improvement in hospitals with excess 30-day mortality after acute myocardial infarction, cerebral stroke and hip fracture: a before-after study.

0.72 million) in the first year, which is equivalent to Norwegian kroner 1.06 per inhabitant (€0.13, US

30-Day Survival Probabilities as a Quality Indicator for Norwegian Hospitals: Data Management and Analysis.

0.16). Conclusions Prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a reimbursement rule requiring the use of thiazides as the first-choice therapy was put into effect. However, the resulting savings on drug expenditures were modest. There were no significant changes in the achievement of treatment goals or in the prescribing of a second antihypertensive drug.

Observed to expected or logistic regression to identify hospitals with high or low 30-day mortality?

Objectives To evaluate survival curves (Kaplan-Meier) as a means of identifying areas in the clinical pathway amenable to quality improvement. Design Observational before–after study. Setting In Norway, annual public reporting of nationwide 30-day in-and-out-of-hospital mortality (30D) for three medical conditions started in 2011: first time acute myocardial infarction (AMI), stroke and hip fracture; reported for 2009. 12 of 61 hospitals had statistically significant lower/higher mortality compared with the hospital mean. Participants Three hospitals with significantly higher mortality requested detailed analyses for quality improvement purposes: Telemark Hospital Trust Skien (AMI and stroke), Østfold Hospital Trust Fredrikstad (stroke), Innlandet Hospital Trust Gjøvik (hip fracture). Outcome measures Survival curves, crude and risk-adjusted 30D before (2008–2009) and after (2012–2013). Interventions Unadjusted survival curves for the outlier hospitals were compared to curves based on pooled data from the other hospitals for the 30-day period 2008–2009. For patients admitted with AMI (Skien), stroke (Fredrikstad) and hip fracture (Gjøvik), the curves suggested increased mortality from the initial part of the clinical pathway. For stroke (Skien), increased mortality appeared after about 8 days. The curve profiles were thought to reflect suboptimal care in various phases in the clinical pathway. This informed improvement efforts. Results For 2008–2009, hospital-specific curves differed from other hospitals: borderline significant for AMI (p=0.064), highly significant (p≤0.005) for the remainder. After intervention, no difference was found (p>0.188). Before–after comparison of the curves within each hospital revealed a significant change for Fredrikstad (p=0.006). For the three hospitals, crude 30D declined and they were non-outliers for risk-adjusted 30D for 2013. Conclusions Survival curves as a supplement to 30D may be useful for identifying suboptimal care in the clinical pathway, and thus informing design of quality improvement projects.