Feedback GAP: pragmatic,cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care

Background

Audit and feedback to physicians is a commonly used quality improvement strategy, but its optimal design is unknown. This trial tested the effects of a theory-informed worksheet to facilitate goal setting and action planning, appended to feedback reports on chronic disease management, compared to feedback reports provided without these worksheets.

Methods

A two-arm pragmatic cluster randomized trial was conducted, with allocation at the level of primary care clinics. Participants were family physicians who contributed data from their electronic medical records. The ‘usual feedback’ arm received feedback every six months for two years regarding the proportion of their patients meeting quality targets for diabetes and/or ischemic heart disease. The intervention arm received these same reports plus a worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Blood pressure (BP) and low-density lipoprotein cholesterol (LDL) values were compared after two years as the primary outcomes. Process outcomes measured the proportion of guideline-recommended actions (e.g., testing and prescribing) conducted within the appropriate timeframe. Intention-to-treat analysis was performed.

Results

Outcomes were similar across groups at baseline. Final analysis included 20 physicians from seven clinics and 1,832 patients in the intervention arm (15% loss to follow up) and 29 physicians from seven clinics and 2,223 patients in the usual feedback arm (10% loss to follow up). Ten of 20 physicians completed the worksheet at least once during the study. Mean BP was 128/72 in the feedback plus worksheet arm and 128/73 in the feedback alone arm, while LDL was 2.1 and 2.0, respectively. Thus, no significant differences were observed across groups in the primary outcomes, but mean haemoglobin A1c was lower in the feedback plus worksheet arm (7.2% versus 7.4%, p<0.001). Improvements in both arms were noted over time for one-half of the process outcomes.

Discussion

Appending a theory-informed goal setting and action planning worksheet to an externally produced audit and feedback intervention did not lead to improvements in patient outcomes. The results may be explained in part by passive dissemination of the worksheet leading to inadequate engagement with the intervention.

Trial registration

ClinicalTrials.gov NCT00996645

     

Evaluation of the performance and accuracy of Global Positioning System bug transmitters deployed on a small mammal

Recent technological advances in Global Positioning System (GPS) telemetry have allowed the production of lightweight devices suitable for use on small mammals. We evaluated the use of GPS bugs on the European hedgehog (Erinaceus europaeus) in a series of static and field tests. Static tests were conducted in five different rural habitats, affording different degrees of obstruction to satellites. GPS bug performance was good in all habitats (fix success rate (FSR): median ≥?66.8 %; location error (LE): mean ≤?13.5 m), except woodland (FSR?=?37.7 %; LE?=?15.6 m), with performance highest in the open pasture habitat (FSR?=?100 %; LE?=?6.4 m). Field tests revealed mean FSR was high (84.6 %), with the use of nesting habitats, the probable cause of most failed fixes. Despite being more expensive, GPS bugs require less survey effort and substantially lower labour costs with unlimited longevity permitting re-use in multiple seasons. We recommend the use of GPS bugs in the spatial ecological study of any small mammal in a rural environment, providing accurate and unbiased movement data. Further performance testing is recommended before deployment on species inhabiting forested habitats where reduced FSR and high LE support the alternative use of very high frequency tracking.