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Theory-based and evidence-based design of audit and feedback programmes: examples from two clinical intervention studies
  1. Sylvia J Hysong1,2,
  2. Harrison J Kell3,
  3. Laura A Petersen1,2,
  4. Bryan A Campbell4,
  5. Barbara W Trautner1,2
  1. 1Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
  2. 2Baylor College of Medicine, Houston, Texas, USA
  3. 3Educational Testing Service, Morrisville, Pennsylvania, USA
  4. 4Normal Modes, Durham, North Carolina, USA
  1. Correspondence to Dr Sylvia Hysong, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston TX 77030, USA; Hysong{at}


Background Audit and feedback (A&F) is a common intervention used to change healthcare provider behaviour and, thus, improve healthcare quality. Although A&F can be effective its effectiveness varies, often due to the details of how A&F interventions are implemented. Some have suggested that a suitable conceptual framework is needed to organise the elements of A&F and also explain any observed differences in effectiveness. Through two examples from applied research studies, this article demonstrates how a suitable explanatory theory (in this case Kluger & DeNisi's Feedback Intervention Theory (FIT)) can be systematically applied to design better feedback interventions in healthcare settings.

Methods Case 1: this study's objective was to reduce inappropriate diagnosis of catheter-associated urinary tract infections (CAUTI) in inpatient wards. Learning to identify the correct clinical course of action from the case details was central to this study; consequently, the feedback intervention featured feedback elements that FIT predicts would best activate learning processes (framing feedback in terms of group performance and providing of correct solution information). We designed a highly personalised, interactive, one-on-one intervention with healthcare providers to improve their capacity to distinguish between CAUTI and asymptomatic bacteruria (ASB) and treat ASB appropriately. Case 2: Simplicity and scalability drove this study's intervention design, employing elements that FIT predicted positively impacted effectiveness yet still facilitated deployment and scalability (eg, delivered via computer, delivered in writing). We designed a web-based, report-style feedback intervention to help primary care physicians improve their care of patients with hypertension.

Results Both studies exhibited significant improvements in their desired outcome and in both cases interventions were received positively by feedback recipients.

Summary A&F has been a popular, yet inconsistently implemented and variably effective tool for changing healthcare provider behaviour and, improving healthcare quality. Through the systematic use of theory such as FIT, robust feedback interventions can be designed that yield greater effectiveness. Future work should look to comparative effectiveness of specific design elements and contextual factors that identify A&F as the optimal intervention to effectuate healthcare provider behaviour change.

Trial registration number NCT01052545, NCT00302718; post-results.

  • Audit and feedback
  • Health services research
  • Quality improvement methodologies

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