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

     

The arbuscular mycorrhizal fungus Diversispora spurca ameliorates effects of waterlogging on growth,root system architecture and antioxidant enzyme activities of citrus seedlings

Citrus plants are often exposed to heavy rain and subsequent periods of soil waterlogging which severely restrict tree growth. We assessed the effect of one arbuscular mycorrhizal fungus species (Diversispora spurca) on growth, root system architecture (RSA), and antioxidant enzyme activities of young citrus (Citrus junos) seedlings. Waterlogging for 37 d significantly restricted mycorrhizal colonization but increased the number of entry points and vesicles. Compared with non-mycorrhizal controls, mycorrhizal seedlings had significantly greater plant height, fresh mass, total root and taproot lengths, projected and surface root areas, root volume, and numbers of lst, 2nd and 3rd order lateral roots regardless of waterlogging treatment. D. spurca significantly increased root catalase (CAT) activity in non-stressed seedlings and increased root soluble protein concentration and leaf CAT activity in waterlogged seedlings, thereby inducing lower oxidative damage. These results suggest that D. spurca ameliorates effects of waterlogging on growth, RSA and antioxidant enzyme activities.