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Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study).

ABSTRACT: BACKGROUND:Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality. OBJECTIVES:The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used. METHODS:An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared. RESULTS:Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group. CONCLUSION:An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.

SUBMITTER: Halpape K

PROVIDER: S-EPMC3952903 | biostudies-other | 2014 Jan

REPOSITORIES: biostudies-other

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Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study).

Halpape Katelyn K Sulz Linda L Schuster Brenda B Taylor Ron R

The Canadian journal of hospital pharmacy 20140101 1

<h4>Background</h4>Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality.<h4>Objectives</h4>The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatmen ...[more]

PMID: 24634522

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Project description:BackgroundThe Department of Veterans Affairs (VA) has led the industry in measuring facility performance as a critical element in improving quality of care, investing substantial resources to develop and maintain valid and cost-effective measures. The External Peer Review Program (EPRP) of the VA is the official data source for monitoring facility performance, used to prioritize the quality areas needing most attention. Facility performance measurement has significantly improved preventive and chronic care, as well as overall quality; however, much variability still exists in levels of performance across measures and facilities. Audit and feedback (A&F), an important component of effective performance measurement, can help reduce this variability and improve overall performance. Previous research suggests that VA Medical Centers (VAMCs) with high EPRP performance scores tend to use EPRP data as a feedback source. However, the manner in which EPRP data are used as a feedback source by individual providers as well as service line, facility, and network leadership is not well understood. An in-depth understanding of mental models, strategies, and specific feedback process characteristics adopted by high-performing facilities is thus urgently needed.This research compares how leaders of high, low, and moderately performing VAMCs use clinical performance data from the EPRP as a feedback tool to maintain and improve quality of care.MethodsWe will conduct a qualitative, grounded theory analysis of up to 64 interviews using a novel method of sampling primary care, facility, and Veterans Integrated Service Network (VISN) leadership at high-, moderate-, and low-performing facilities. We will analyze interviews for evidence of cross-facility differences in perceptions of performance data usefulness and strategies for disseminating performance data evaluating performance, with particular attention to timeliness, individualization, and punitiveness of feedback delivery.DiscussionMost research examining feedback to improve provider and facility performance lacks a detailed understanding of the elements of effective feedback. This research will highlight the elements most commonly used at high-performing facilities and identify additional features of their successful feedback strategies not previously identified. Armed with this information, practices can implement more effective A&F interventions to improve quality of care.

Project description:Clinical audits have emerged as a potential tool to summarize the clinical performance of healthcare over a specified period of time. However, the effectiveness of audit and feedback has shown inconsistent results and the impact of audit and feedback on clinical performance has not been evaluated for COPD exacerbations. In the present study, we analyzed the results of two consecutive nationwide clinical audits performed in Spain to evaluate both the in-hospital clinical care provided and the feedback strategy.The present study is an analysis of two clinical audits performed in Spain that evaluated the clinical care provided to COPD patients who were admitted to the hospital for a COPD exacerbation. The first audit was performed from November-December 2008. The feedback strategy consisted of personalized reports for each participant center, the presentation and discussion of the results at regional, national and international meetings and the creation of health-care quality standards for COPD. The second audit was part of a European study during January and February 2011. The impact of the feedback strategy was evaluated in term of clinical care provided and in-hospital survival.A total of 94 centers participated in the two audits, recruiting 8,143 admissions (audit 1?3,493 and audit 2?4,650). The initially provided clinical care was reasonably acceptable even though there was considerable variability. Several diagnostic and therapeutic procedures improved in the second audit. Although the differences were significant, the degree of improvement was small to moderate. We found no impact on in-hospital mortality.The present study describes COPD hospital care in Spanish hospitals and evaluates the impact of peer-benchmarked, individually written and group-oral feedback strategy on the clinical outcomes for treating COPD exacerbations. It describes small to moderate improvements in the clinical care provided to COPD patients with no impact on in-hospital mortality.

Project description:Background: Routine clinical data are widely used in many countries to monitor quality of care. A limitation of routine data is missing information which occurs due to lack of documentation of care processes by health care providers, poor record keeping, or limited health care technology at facility level. Our objective was to address missing covariates while properly accounting for hierarchical structure in routine pediatric pneumonia care. Methods: We analyzed routine data collected during a cluster randomized trial to investigating the effect of audit and feedback (A&F) over time on inpatient pneumonia care among children admitted in 12 Kenyan hospitals between March and November 2016. Six hospitals in the intervention arm received enhance A&F on classification and treatment of pneumonia cases in addition to a standard A&F report on general inpatient pediatric care. The remaining six in control arm received standard A&F alone. We derived and analyzed a composite outcome known as Pediatric Admission Quality of Care (PAQC) score. In our analysis, we adjusted for patients, clinician and hospital level factors. Missing data occurred in patient and clinician level variables. We did multiple imputation of missing covariates within the joint model imputation framework. We fitted proportion odds random effects model and generalized estimating equation (GEE) models to the data before and after multilevel multiple imputation. Results: Overall, 2,299 children aged 2 to 59 months were admitted with childhood pneumonia in 12 hospitals during the trial period. 2,127 (92%) of the children (level 1) were admitted by 378 clinicians across the 12 hospitals. Enhanced A&F led to improved inpatient pediatric pneumonia care over time compared to standard A&F. Female clinicians and hospitals with low admission workload were associated with higher uptake of the new pneumonia guidelines during the trial period. In both random effects and marginal model, parameter estimates were biased and inefficient under complete case analysis. Conclusions: Enhanced A&F improved the uptake of WHO recommended pediatric pneumonia guidelines over time compared to standard audit and feedback. When imputing missing data, it is important to account for the hierarchical structure to ensure compatibility with analysis models of interest to alleviate bias.

Project description:BackgroundMany primary care sites have implemented models to improve detection, diagnosis, and management of dementia, as per Canadian guidelines. The aim of this study is to describe the responses of clinicians, managers, and staff of sites that have implemented these models when presented with audit results, their insights on the factors that explain their results, their proposed solutions for improvement and how these align to one another.MethodsOne audit and feedback cycle was carried out in eight purposefully sampled sites in Ontario, Canada, that had previously implemented dementia care models. Audit consisted of a) chart review to assess quality of dementia care indicators, b) questionnaire to assess the physicians' knowledge, attitudes and practice toward dementia care, and c) semi-structured interviews to understand barriers and facilitators to implementing these models. Feedback was given to clinicians, managers, and staff in the form of graphic and oral presentations, followed by eight focus groups (one per site). Discussions revolved around: what audit results elicited more discussion from the participants, 2) their insights on the factors that explain their audit results, and 3) solutions they propose to improve dementia care. Deductive content and inductive thematic analyses, grounded in causal pathways models' theory was performed.FindingsThe audit and feedback process allowed the 63 participants to discuss many audit results and share their insights on a) organizational factors (lack of human resources, the importance of organized links with community services, clear roles and support from external memory clinics) and b) clinician factors (perceived competency practice and attitudes on dementia care), that could explain their audit results. Participants also provided solutions to improve dementia care in primary care (financial incentives, having clear pathways, adding tools to improve chart documentation, establish training on dementia care, and the possibility of benchmarking with other institutions). Proposed solutions were well aligned with their insights and further nuanced according to contextual details.ConclusionsThis study provides valuable information on solutions proposed by primary care clinicians, managers, and staff to improve dementia care in primary care. The solutions are grounded in clinical experience and will inform ongoing and future dementia strategies.

Project description:BackgroundThere is a significant variation among individual primary care providers in prescribing of potentially problematic, low-value medicines which cause avoidable patient harm. Audit and feedback is generally effective at improving prescribing. However, progress has been hindered by research waste, leading to unanswered questions about how to include audit and feedback for specific problems and circumstances. Trials of different ways of providing audit and feedback in implementation laboratories have been proposed as a way of improving population healthcare while generating robust evidence on feedback effects. However, there is limited experience in their design and delivery.AimTo explore priorities, feasibility, and ethical challenges of establishing a primary care prescribing audit and feedback implementation laboratory.Design and settingTwo-stage Delphi consensus process involving primary care pharmacy leads, audit and feedback researchers, and patient and public.MethodParticipants initially scored statements relating to priorities, feasibility, and ethical considerations for an implementation laboratory. These covered current feedback practice, priority topics for feedback, usefulness of feedback in improving prescribing and different types of prescribing data, acceptability and desirability of different organization levels of randomization, options for trial consent, different methods of delivering feedback, and interest in finding out how effective different ways of presenting feedback would be. After receiving collated results, participants then scored the items again. The consensus was defined using the GRADE criteria. The results were analyzed by group and overall score.ResultsFourteen participants reached consensus for 38 out of 55 statements. Addressing antibiotic and opioid prescribing emerged as the highest priorities for action. The panel supported statements around addressing high-priority prescribing issues, taking an "opt-out" approach to practice consent if waiving consent was not permitted, and randomizing at lower rather than higher organizational levels. Participants supported patient-level prescribing data and further research evaluating most of the different feedback methods we presented them with.ConclusionsThere is a good level of support for evaluating a wide range of potential enhancements to improve the effects of feedback on prescribing. The successful design and delivery of a primary care audit and feedback implementation laboratory depend on identifying shared priorities and addressing practical and ethical considerations.

Project description:BackgroundAudit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator.MethodsWe described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis.ResultsWe found across 146 trials that feedback recipients' performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients' own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies.ConclusionClinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback's credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information.

Project description:BackgroundThe use of clinical performance feedback to support quality improvement (QI) activities is based on the sound rationale that measurement is necessary to improve quality of care. However, concerns persist about the reliability of this strategy, known as Audit and Feedback (A&F) to support QI. If successfully implemented, A&F should reflect an iterative, self-regulating QI process. Whether and how real-world A&F initiatives result in this type of feedback loop are scarcely reported. This study aimed to identify barriers or facilitators to implementation in a team-based primary care context.MethodsSemi-structured interviews were conducted with key informants from team-based primary care practices in Ontario, Canada. At the time of data collection, practices could have received up to three iterations of the voluntary A&F initiative. Interviews explored whether, how, and why practices used the feedback to guide their QI activities. The Consolidated Framework for Implementation Research was used to code transcripts and the resulting frameworks were analyzed inductively to generate key themes.ResultsTwenty-five individuals representing 18 primary care teams participated in the study. Analysis of how the A&F intervention was used revealed that implementation reflected an incomplete feedback loop. Participation was facilitated by the reliance on an external resource to facilitate the practice audit. The frequency of feedback, concerns with data validity, the design of the feedback report, the resource requirements to participate, and the team relationship were all identified as barriers to implementation of A&F.ConclusionsThe implementation of a real-world, voluntary A&F initiative did not lead to desired QI activities despite substantial investments in performance measurement. In small primary care teams, it may take long periods of time to develop capacity for QI and future evaluations may reveal shifts in the implementation state of the initiative. Findings from the present study demonstrate that the potential mechanism of action of A&F may be deceptively clear; in practice, moving from measurement to action can be complex.

Dataset Information

Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study).

Publications

Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study).

Similar Datasets

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