Cited by 918Health Policy Implementation ScienceClinical practice guidelines implementationHealth Sciences Research and Education

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Audit and feedback: effects on professional practice and health care outcomes

Jamtvedt, Gro, Young, Jane M, Kristoffersen, Doris Tove, O'Brien, Mary Ann, Oxman, Andrew D·2006·Cochrane Database of Systematic Reviews

DOI 10.1002/14651858.cd000259.pub2

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Abstract

BACKGROUND: Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective. OBJECTIVES: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004. SELECTION CRITERIA: Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality. MAIN RESULTS: Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies. AUTHORS' CONCLUSIONS: Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

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Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes
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BackgroundResult
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Martens, J. D., van der Weijden, T., Severens, J. L., de Clercq, P. A., Bruijn‐Geraets, D. P. D., Kester, A. D. M., & Winkens, R. A. G. (2007) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2007.04.005 · Cited by 63
Effectiveness of Peer Assessment for Implementing a Dutch Physical Therapy Low Back Pain Guideline: Cluster Randomized Controlled Trial
van Dulmen, S. A., Maas, M. J. M., Staal, J. B., Rutten, G. M., Kiers, H., der Sanden, M. W. G. N., & van der Wees, P. J. (2014) · Physical Therapy · doi:10.2522/ptj.20130286 · Cited by 62
Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study
Mold, J. W., Aspy, C. A., & Nagykaldi, Z. (2008) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2008.04.080006 · Cited by 61
Feedback as a strategy to change behaviour: the devil is in the details
Larson, E., Patel, S. J., Evans, D. J., & Saiman, L. M. (2011) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2011.01801.x · Cited by 61
Does Feedback Improve the Quality of Computerized Medical Records in Primary Care?
de Lusignan, S. (2002) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1023 · Cited by 62
Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion‐based audit at two Tanzanian rural hospitals
Maaløe, N., Sorensen, B., Onesmo, R., SECHER, N. J., & Bygbjerg, I. C. (2012) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/j.1471-0528.2012.03284.x · Cited by 62
Practice patterns for peer review in radiation oncology
Hoopes, D. J., Johnstone, P. A. S., Chapin, P. S., Kabban, C. M. S., Lee, W. R., Chen, A. B., Fraass, B. A., Skinner, W. J. K., & Marks, L. B. (2014) · Practical Radiation Oncology · doi:10.1016/j.prro.2014.04.004 · Cited by 62
Interventions to reduce primary care delay in cancer referral: a systematic review
Mansell, G., Shapley, M., Jordan, J. L., & Jordan, K. P. (2011) · British Journal of General Practice · doi:10.3399/bjgp11x613160 · Cited by 62
“More bang for the buck”: exploring optimal approaches for guideline implementation through interviews with international developers
Gagliardi, A. R. (2012) · BMC Health Services Research · doi:10.1186/1472-6963-12-404 · Cited by 63
Interventions to improve hand hygiene compliance in patient care
Gould, D. J., Chudleigh, J. H., Moralejo, D. G., & Drey, N. (2007) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd005186.pub2 · Cited by 62
Interventions targeted at women to encourage the uptake of cervical screening
Staley, H., Shiraz, A., Shreeve, N., Bryant, A., Martin‐Hirsch, P. L., & Gajjar, K. B. (2021) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd002834.pub3 · Cited by 61
Implementing quality improvement strategies to reduce healthcare-associated infections: A systematic review
Mauger, B., Marbella, A. M., Pines, E., Chopra, R., Black, E. R., & Aronson, N. (2014) · American Journal of Infection Control · doi:10.1016/j.ajic.2014.05.031 · Cited by 63
Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review
Rowe, A. K., Rowe, S., Holloway, K., Ivanovska, V., Muhe, L. M., & Lambrechts, T. (2011) · Health Policy and Planning · doi:10.1093/heapol/czr033 · Cited by 60
“size, was available for all studies and has been used in other reviews (Jamtvedt et al. 2006; Rowe et al. 2009b).”
MethodResult
The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Older Adults with Diabetes Mellitus
Lee, S. J., Boscardin, W. J., Cenzer, I. S., Huang, E. S., Rice‐Trumble, K., & Eng, C. (2011) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2011.03362.x · Cited by 63
“Nevertheless, there is striking variation, with some studies reporting strong effects (up to 70% increase in adherence), and other studies reporting no effects.(34) Because On Lok is a small, closed system, with salaried clinicians and modest provider turnover ( 5% per year), the education, feedback, and monitoring ap…”
Result
Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review
Papoutsi, C., Mattick, K. L., Pearson, M., Brennan, N., Briscoe, S., & Wong, G. (2018) · Health Services and Delivery Research · doi:10.3310/hsdr06100 · Cited by 62
Implementing Colorectal Cancer Screening in Community Health Centers
Taplin, S. H., Haggstrom, D. A., Jacobs, T., Determan, A., Granger, J., Montalvo, W., Snyder, W. M., Lockhart, S., & Calvo, A. (2008) · Medical Care · doi:10.1097/mlr.0b013e31817fdf68 · Cited by 59
Do multidisciplinary cancer care teams suffer decision-making fatigue: an observational, longitudinal team improvement study
Soukup, T., Gandamihardja, T., McInerney, S., Green, J. S. A., & Sevdalis, N. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-027303 · Cited by 62
“Such approach was found effective in improving practice and supporting quality improvements, and can be used to aid implementation of evidence-based interventions.(41) Within our study, this approach allowed us to elicit inputs from all team members, which we then used to codesign interventions to best meet the needs…”
Method
Promising Practices for Achieving Patient-centered Hospital Care
Aboumatar, H. J., Chang, B. H., Danaf, J. A., Shaear, M., Namuyinga, R. J., Elumalai, S., Marsteller, J. A., & Pronovost, P. J. (2015) · Medical Care · doi:10.1097/mlr.0000000000000396 · Cited by 64
“These behaviors are also part of every employee’s performance evaluation and account for 35% of their merit increase Strategies to enhance patient education 22 (42) 18 (43) 4 (40) The staff use teach back methods to assure that patients and families are truly understanding the information/education being delivered”
BackgroundMethod
Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review
Ista, E., van Dijk, M., & van Achterberg, T. (2012) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2012.11.003 · Cited by 60
Improvements in Pain Outcomes in a Canadian Pediatric Teaching Hospital Following Implementation of a Multifaceted, Knowledge Translation Initiative
Zhu, L. M., Stinson, J., Palozzi, L., Weingarten, K., Hogan, M., Duong, S., Carbajal, R., Campbell, F. A., & Taddio, A. (2012) · Pain Research and Management · doi:10.1155/2012/586589 · Cited by 58
More Than Money: Motivating Physician Behavior Change in Accountable Care Organizations
Phipps-Taylor, M., & Shortell, S. M. (2016) · Milbank Quarterly · doi:10.1111/1468-0009.12230 · Cited by 71
“Mastery 1 (60) 1 (29) 1 (36) 1 (63) Social purpose 2 (20) 2 (19) 5 (21) 2 (19) Financial motivators 5 (34) 5 (21) 2 (38) 3 (31) Hygiene factors 4 (18) 3 (27) 3 (38) 3 (30) Relatedness 3 (25) 3 (17) 5 (23) 5 (18) Autonomy and power 5 (16) 5 (9) 4 (23) 6 (14)”
Validation of Team Performance Assessment of Multidisciplinary Tumor Boards
Jalil, R. T., Akhter, W., Lamb, B. W., Taylor, C., Harris, J., Green, J. S. A., & Sevdalis, N. (2014) · The Journal of Urology · doi:10.1016/j.juro.2014.03.002 · Cited by 57
Identifying Practice Facilitation Delays and Barriers in Primary Care Quality Improvement
Ye, J., Zhang, R., Bannon, J. E., Wang, A. A., Walunas, T. L., Kho, A., & Soulakis, N. D. (2020) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2020.05.200058 · Cited by 57
“17,26 This study is the ﬁ rst to quantify irregular intervals between facilitation activities, and demonstrate their negative association with project completion.”
Background
Methodology and tools for quality improvement in maternal and newborn health care
Raven, J., Hofman, J., Adegoke, A., & van den Broek, N. (2011) · International Journal of Gynecology & Obstetrics · doi:10.1016/j.ijgo.2011.02.007 · Cited by 68
“A review of randomized controlled studies from Uganda, Thailand, and Laos [32] similarly showed a positive effect of audit and feedback on healthcare practice and healthcare outcomes, although the effect size was modest.”
Background
Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action
Gunningberg, L., Donaldson, N. E., Aydin, C., & Idvall, E. (2011) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2011.01702.x · Cited by 56
Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients
Titler, M. G., Herr, K., Brooks, J. M., Xie, X., Ardery, G., Schilling, M. L., Marsh, J. L., Everett, L. Q., & Clarke, W. R. (2009) · Health Services Research · doi:10.1111/j.1475-6773.2008.00913.x · Cited by 56
“PGA and A/F have consistently shown a positive effect on changing practice behavior of providers (Bradley et al. 2004; Horbar et al. 2004; Hysong, Best, and Pugh 2006; Jamtvedt et al. 2006).”
Background
Interventions to Improve Trainers' Learning and Behaviors for Educating Health Care Professionals Using Train-the-Trainer Method: A Systematic Review and Meta-analysis
Poitras, M.-È., Bélanger, É., Vaillancourt, V. T., Kienlin, S. M., Körner, M., Godbout, I., Bernard‐Hamel, J., O'Connor, S. E., Blanchette, P. L., Khadhraoui, L., et al. (2021) · Journal of Continuing Education in the Health Professions · doi:10.1097/ceh.0000000000000375 · Cited by 55
“Outcomes relevant to continuing education include knowledge, attitudes, skills, competencies, commitment, and behavior.(11) Reviews on training interventions have demonstrated improved efficiency with dissemination of information, enhanced knowledge of trainees,(12) better patient health outcomes, and more efficient u…”
Background
Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi
Kongnyuy, E. J., Leigh, B., & van den Broek, N. R. (2008) · Women and Birth · doi:10.1016/j.wombi.2008.08.002 · Cited by 55
Task shifting in maternal and child health care: An evidence brief for Uganda
Nabudere, H., Asiimwe, D., & Mijumbi, R. (2011) · International Journal of Technology Assessment in Health Care · doi:10.1017/s0266462311000055 · Cited by 55
“Health workers lack necessary knowledge and competency to expand their roles (27) Educational meetings (training workshops), educational outreach (a personal visit by a trained person to health workers in their own settings) and audit and feedback (a summary of performance over a specified period of time given in a wr…”
Method
Improving Test Ordering in Primary Care: The Added Value of a Small-Group Quality Improvement Strategy Compared With Classic Feedback Only
Verstappen, W. H. J. M. (2004) · The Annals of Family Medicine · doi:10.1370/afm.244 · Cited by 55
Improving patient safety by examining pathology errors
Raab, S. S. (2004) · Clinics in Laboratory Medicine · doi:10.1016/j.cll.2004.05.014 · Cited by 55
Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial
Caminiti, C., Meschi, T., Braglia, L., Diodati, F., Iezzi, E., Marcomini, B., Nouvenne, A., Palermo, E., Prati, B., Schianchi, T., et al. (2013) · BMC Health Services Research · doi:10.1186/1472-6963-13-14 · Cited by 54
“In fact, a systematic review of randomized trials reporting objectively measured outcomes has shown that A/F can be effective in improving professional practice, particularly when baseline adherence to recommended practice is low [17].”
Background
SUPPORT Tools for evidence-informed health Policymaking (STP) 8: Deciding how much confidence to place in a systematic review
Lewin, S. A., Oxman, A. D., Lavis, J. N., & Fretheim, A. (2009) · Health Research Policy and Systems · doi:10.1186/1478-4505-7-s1-s8 · Cited by 57
Self-citation
Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit
Kayiga, H., Ajeani, J., Kiondo, P., & Kaye, D. K. (2016) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-016-0949-1 · Cited by 53
Strategies for improving the quality of care in psoriasis with the use of treatment goals – a report on an implementation meeting
Mrowietz, U., Kragballe, K., Nast, A., & Reich, K. (2011) · Journal of the European Academy of Dermatology and Venereology · doi:10.1111/j.1468-3083.2011.04033.x · Cited by 53
Return to work and occupational physicians’ management of common mental health problems – process evaluation of a randomized controlled trial
Rebergen, D. S., Bruinvels, D. J., Bos, C. M., van der Beek, A. J., & van Mechelen, W. (2010) · Scandinavian Journal of Work Environment & Health · doi:10.5271/sjweh.3084 · Cited by 54
“However, an audit of medical records is, as any observational study, susceptible to bias (31).”
Background
How Well Is Acute Pain in Children Managed? A Snapshot in One English Hospital
Twycross, A. M., & Collis, S. (2012) · Pain Management Nursing · doi:10.1016/j.pmn.2012.01.003 · Cited by 53
Continuous quality improvement: effects on professional practice and healthcare outcomes
Brennan, S., McKenzie, J. E., Whitty, P., Buchan, H., & Green, S. (2009) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd003319.pub2 · Cited by 54
Retracted
Characteristics of Antimicrobial Stewardship Programs at Veterans Affairs Hospitals: Results of a Nationwide Survey
Chou, A. F., Graber, C. J., Jones, M., Zhang, Y., Goetz, M. B., Madaras‐Kelly, K., Samore, M. H., Kelly, A. A., & Glassman, P. A. (2016) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2016.26 · Cited by 53
“Therefore, it is a priority to identify effective strategies, and the factors that impact the implementation of those strategies, for modifying inappropriate antimicrobial prescribing behaviors.(27) Our study objective was to better characterize variations of existing AS structural aspects and practices across a natio…”
Background
Challenges to Measuring Outcomes in Occupational Therapy: A Qualitative Focus Group Study
Bowman, J. (2006) · British Journal of Occupational Therapy · doi:10.1177/030802260606901005 · Cited by 52
Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients' engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial
Killaspy, H. T., Marston, L., Green, N., Harrison, I., Lean, M., Cook, S., Mundy, T., Craig, T., Holloway, F. A., Leavey, G., et al. (2015) · The Lancet Psychiatry · doi:10.1016/s2215-0366(14)00050-9 · Cited by 55
Evaluating the impact of an intensive education workshop on evidence-informed decision making knowledge, skills, and behaviours: a mixed methods study
Yost, J., Ciliska, D. K., & Dobbins, M. (2014) · BMC Medical Education · doi:10.1186/1472-6920-14-13 · Cited by 58
Professionals’ perceptions of their patients’ experiences with fertility care
Aarts, J. W. M., Faber, M. J., van Empel, I. W. H., Scheenjes, E., Nelen, W. L. D. M., & Kremer, J. A. M. (2011) · Human Reproduction · doi:10.1093/humrep/der054 · Cited by 52
“Although there is no consistent proof of effectiveness in the literature (Vingerhoets et al., 2001; Jamtvedt et al., 2006; Cheragi-Sohi et al., 2008; Hysong, 2009), we suggest providing fertility care professionals with feedback about patient-centredness that is as detailed as possible.”
Background
Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review
Crayton, E., Richardson, M. A., Fuller, C., Smith, C. M., Liu, S., Forbes, G., Anderson, N., Shallcross, L. J., Michie, S., Hayward, A. C., et al. (2020) · BMC Geriatrics · doi:10.1186/s12877-020-01564-1 · Cited by 56
“One particular type of enablement intervention is audit and feedback, defined as a “summary of the clinical performance of healthcare provider(s) over a specified period of time” [72, 73].”
Background
Surgical decision making
Francis, D. M. (2009) · ANZ Journal of Surgery · doi:10.1111/j.1445-2197.2009.05139.x · Cited by 52
“Feedback obtained from audit processes can be effective in improving surgical practice, especially when adherence to accepted surgical principles and procedure has been poor.(14) Surgical trainees should make every effort not only to attend but also to participate actively in audit and clinical review meetings so as t…”
Background
Setting the standard for routine asthma consultations: a discussion of the aims, process and outcomes of reviewing people with asthma in primary care
Pinnock, H., Fletcher, M. J., Holmes, S., Keeley, D., Leyshon, J., Price, D. B., Russell, R. E. K., Versnel, J., & Wagstaff, B. (2010) · Primary Care Respiratory Journal · doi:10.4104/pcrj.2010.00006 · Cited by 51
Impact of a real‐time peer review audit on patient management in a radiation oncology department
Boxer, M. M., Forstner, D. F., Kneebone, A. B., Delaney, G. P., Koh, E., Fuller, M., & Kaadan, N. (2009) · Journal of Medical Imaging and Radiation Oncology · doi:10.1111/j.1754-9485.2009.02096.x · Cited by 51
Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives
Becich, M. J., Gilbertson, J. R., Gupta, D., Patel, A. A., Grzybicki, D. M., & Raab, S. S. (2004) · Clinics in Laboratory Medicine · doi:10.1016/j.cll.2004.05.019 · Cited by 51
Challenge of Changing Nursing Home Prescribing Culture
Tjia, J., Gurwitz, J. H., & Briesacher, B. A. (2012) · The American Journal of Geriatric Pharmacotherapy · doi:10.1016/j.amjopharm.2011.12.005 · Cited by 52

Authors: Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O'Brien, M. A., & Oxman, A. D.
Affiliations: Nasjonalt Kunnskapssenter for Helsetjenesten (NO)
ORCID: Jamtvedt, Gro
Young, Jane M
Kristoffersen, Doris Tove
Oxman, Andrew D
Venue: Cochrane Database of Systematic Reviews
Publisher: John Wiley & Sons, Ltd
Published: 2006-04-19
Issue: 2
Pages: CD000259-CD000259
ISSN: 1361-6137 (ISSN-L)
DOI: 10.1002/14651858.cd000259.pub2
OpenAlex: W4245034287
Cited by: 912
References: 207
Citations by year: 2026: 4 · 2025: 8 · 2024: 10 · 2023: 23 · 2022: 13 · 2021: 27 · 2020: 23 · 2019: 18 · 2018: 31 · 2017: 42 · 2016: 38 · 2015: 55 · 2014: 45 · 2013: 133 · 2012: 82
Type: reference entry
Language: en
Update notices: new_version (2012-06-13)
Open access: closed
Locations: Cochrane Database of Systematic Reviews (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Keywords: audit and feedback, professional practice change, guideline adherence, health care outcomes, multicomponent intervention, educational meetings, intervention intensity, behavior change, quality improvement, patient outcomes, healthcare workers, meta-regression, study quality, risk difference, relative risk, continuous outcomes, binary outcomes
MeSH terms: Education, Medical, Continuing, Health Personnel, Health Services Research, Humans, Medical Audit, Practice Patterns, Physicians', Professional Practice, Outcome Assessment, Health Care, Feedback, Psychological

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Audit and feedback: effects on professional practice and health care outcomes

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