Optimizing Audit and Feedback to Improve Quality in Primary Care

One of the most consistent findings in health services research relates to gaps between ideal and actual care. Audit and feedback is frequently implemented to help providers identify these gaps and to subsequently improve quality of care, with widely varying results. The overall aim of this thesis was to examine how to optimize audit and feedback interventions provided to family physicians to more reliably result in professional behaviour change that will benefit patients. A systematic review, meta-analysis, and meta-regression was conducted to determine the effect of audit and feedback interventions on quality of care and to identify effect modifiers. The review included 140 trials and found that audit and feedback works best when 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. Based on the latter finding and applying principles from relevant behaviour change theories, a worksheet was developed to guide feedback recipients in setting appropriate goals and action plans in response to identified gaps in care. This worksheet was tested in a pragmatic, cluster-randomized trial including 53 family physicians from 14 practices across Ontario. All participating family physicians received feedback every six months regarding the proportion of patients with diabetes and/or heart disease receiving guideline-recommended care. Family physicians in the intervention group also received the worksheet appended to the feedback reports. After two years, no significant effects differences were found between the groups, in part because of poor uptake of the worksheet. An embedded qualitative evaluation examined the barriers and facilitators to improving quality of care for chronic disease management perceived by family physicians who received the feedback reports. Findings highlighted the importance of matching the targeted behaviour change(s) with the priorities and capabilities of recipients and their organizations.Ph.D