CASE 2: Background and Objective • Audit and feedback (A&F) is a common intervention used to change health care provider behavior and improve health care quality. • Yet after 25 years of A&F research in healthcare, we still do not clearly understand what distinguishes successful A&F interventions from unsuccessful ones 1 • A conceptual framework is needed to organize the elements of A&F and offer plausible explanations for observed differences in effectiveness. 2 • Kluger and DeNisi’s 3 Feedback Intervention Theory (FIT) elegantly addresses this gap. • Objective: Demonstrate how FIT can be systematically applied in health care settings to design better feedback interventions, through two case examples from applied research studies. • Objective: Improve VA medical residents’ capacity to distinguish between asymptomatic bacteriuria (ABU) and catheter-associated urinary tract infection (CAUTI). • Participants: 154 internal medicine residents at two VA Medical Centers (VAMC) in the southwest. • Behaviors to be changed: Inappropriate diagnosis and treatment of ABU as CAUTI. ABU cases were identified via chart review by trained experts using a treatment flowchart derived from the Infectious Diseases Society of America (IDSA) guidelines for the non-treatment of ABU. • Intervention: Trained experts contacted residents to deliver case-specific feedback face-to-face. For each case, a flowchart was prepared and used as an explanatory device during the feedback meeting (Fig. • Objective: Help physicians meet guideline- recommended goals for controlling patients’ hypertension. • Participants: 77 primary care physicians at 12 geographically dispersed VAMCs. • Behaviors to be changed: Prescription of guideline- recommended hypertension therapy, blood pressure control, and appropriate clinical response to uncontrolled blood pressure according to the guidelines established in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). • Intervention: Over 20 months, participants in all study arms received five web-based A&F reports at 4-month 1. According to the guidelines, the first thing to do is to check whether the patient had any of the following symptoms: fever, acute hematuria, delirium, rigors, flank pain, pelvic discomfort, urgency, frequency, dysuria, or suprapubic pain. Correct: You decided YES, The patient had fever, which is consistent with CAUTI by IDSA guidelines. Examples from the Field Case-Specific Feedback To Reduce Inappropriate Diagnosis of CAUTI CASE 1: Summary Feedback to Improve Hypertension Management Note: Red callout box denotes the screen to which the user hyperlinks from each of the hyperlinked decisions. The hyperlinks (indicated by the blue boxes) denote the choices originally made by the physician handling the case. Evidence-Based Design of Audit and Feedback Programs: Lessons Learned from Two Clinical Intervention Studies Sylvia J. Hysong 1,2 , Harrison J. Kell 1,3 , Laura A. Petersen 1,2 , & Barbara W. Trautner 1,2 1 Michael E. DeBakey VA Medical Center, 2 Baylor College of Medicine, 3 Vanderbilt University • No comparison case study demonstrating feedback intervention designed without using a theory-based approach. explanatory device during the feedback meeting (Fig. 1). Experts then reviewed the flowchart verbally with the resident step by step, using a standardized script. • Feedback Characteristics Incorporated: Graphical format, correct solution information, standardized, task- based content neutral in tone. • Results: Feedback givers reported most residents to be thoughtful, open to suggestions, and motivated to improve during their 5-10 minute feedback session. Residents receiving A&F exhibited a 40% reduction in unnecessary screening for asymptomatic bacteriuria, compared to residents at the control site (P=0.04, Wilcoxon). At the intervention site, the residents’ specificity in diagnosing asymptomatic bacteriuria improved from 0.63 to .79, versus from 0.71 to 0.74 at the control site. 5 arms received five web-based A&F reports at 4-month intervals (Figure 2). Reports displayed each physician’s (and in some cases their clinic’s) percentage scores for: each of the aforementioned behaviors. Suggested performance goals for the subsequent period were also included. • Feedback Characteristics Incorporated: Graphical (not shown) & written format, goals, normative information. • Results: Physicians reported that the feedback delivered by this intervention was more useful and meaningful than what they regularly receive from their facilities. Prescription of guideline-recommended hypertension therapy improved significantly (p<0.01) for all study arms over the course of the study in unadjusted analyses. 6 Overview of Feedback Intervention Theory • Feedback interventions work by providing new information that redirects recipients’ attention either away from or toward the details of the task. • Phenomena that direct attention toward the details of their task augment the effect of feedback on performance • Phenomena that direct attention away from their task weaken feedback’s impact on performance. Feedback Characteristics that Improve its Effectiveness 3,4 • Graphical and written format, rather than solely verbal • Including information about how to do the task correctly • Providing normative information • Setting S.M.A.R.T. goals for future performance • Task-related and neutral content, rather than praising or discouraging the individual. Limitation • FIT can be used successfully in highly diverse situations as a guide to design feedback interventions that will more effectively improve provider performance and quality of health care. • Adopting a more theory-based approach to A&F design can lead to interventions that improve care more effectively, and improve policymakers’ return on investment. Conclusions and Implications for Policy, Delivery, and Practice Next Step: If the patient does have symptoms that could indicate CAUTI, then you should next consider whether another diagnosis could account for the symptoms. References 1. Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D. et al. (2012). Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev., 6, CD000259. 2. Foy, R., Eccles, M. P., Jamtvedt, G., Young, J., Grimshaw, J.M., &Baker, R. (2005). What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review. BMC Health Services Research, 13: 5-50. 3. Kluger, A. N., & DeNisi, A. 1996. The effects of feedback interventions on performance: A historical review, a meta-analysis, and a preliminary Feedback Intervention Theory. Psychological Bulletin, 116: 254-284 4. Hysong, S. J. (2009). Meta-analysis: Audit and feedback features impact effectiveness on care quality. Medical Care, 47: 1-8 5. Cadena-Zuluaga JA, Trautner BW. (2012) Effect of Audit and Feedback of Catheter Associated Urinary Tract Infection Management in Culture Rates at Two Healthcare Systems. Infectious Disease Society of America, San Diego, CA, October 17. 6. Petersen LA, Simpson K, Pietz K, Lutschg MZ, Hysong SJ, Profit J, Petzel R, Woodard LD. (2012) Do Financial Incentives for Guideline Adherence Improve Care of Hypertension in the VA Primary Care Setting? A Multi-Site Randomized Trial. VA HSR&D Annual Meeting, July 16-19, Washington, DC. Funding: This research was generously supported by a Research Project Grant and Investigator Research Supplement from the National Heart Lung and Blood Institute, grant no. 1R01HL079173, and by the Department of Veterans Affairs Health Services Research and Development Program, grant nos. IIR-04-349, IIR- 09-104, HFP-90-020, and CDA-07-0818. For copies of this poster, please send an e-mail to Sylvia Hysong at hysong@bcm.edu , or visit her ResearchGate profile https://www.researchgate.net/profile/Sylvia_Hysong/. Figure 1. Sample case-specific feedback flowchart for CAUTI case Figure 2. Sample Summary Feedback Report for Hypertension case Your Scores This Period # of patients (%) You earned Number of eligible hypertensive patients randomly sampled from your panel/group 40 Number of patients who received guideline-recommended BP medications 33 (83%) $300.30 Congratulations! You are among the top 10% of performers across the entire study for this outcome period Number of patients with controlled BP 29 (73%) $263.90 Number of patients with uncontrolled BP… 11 (28%) … who received appropriate treatment this period 04 (36%) $36.40 Total Earnings This period – Congratulations! Good work! $600.60 Overall $600.60 Your Goals for the Upcoming Period % of patients Percent of eligible hypertensive patients in your panel/group… … who will receive guideline-recommended BP medications For the next period, your goal is to maintain or exceed your current performance level on this outcome. Keep up the great work! 83% … with controlled BP 82% … with uncontrolled BP who will receive appropriate treatment 77% If you meet or exceed your goals next period, you and your group could earn at least: $627.90 View publication stats View publication stats