Ongoing provision of individual clinician performance data improves practice behavior.
BACKGROUND
Clinical practice guidelines summarize evidence from science and attempt to translate those findings into clinical practice. Pervasive and consistent adoption of these guidelines into daily provider practice has proven slow.


METHODS
Using postoperative nausea and vomiting (PONV) prophylaxis guideline compliance as our metric, we compared the effects of continuing medical education (CME) alone (I), CME with a single snapshot of provider compliance (II), and ongoing reporting of provider compliance data without further CME (III). We retrospectively analyzed guideline compliance of 23,279 anesthetics at the University of Texas M.D. Anderson Cancer Center. Compliance was defined as a patient with 1 risk factor for PONV receiving at least 1 antiemetic, 2 risk factors receiving at least 2 antiemetics, and 3 risk factors receiving at least 3 antiemetics. Drugs of the same class were counted as single antiemetic administration. Propofol-based anesthetic techniques were counted as receiving 1 antiemetic. Patients with 0 risk factors for PONV were not included. We estimated the compliance rates for each of the 4 time periods of the study adjusting for multiple observations on the same clinician. Individual performance feedback was given once at 6 months after intervention I coincident with a refresher presentation on PONV (start of intervention II) and on an ongoing quarterly basis during intervention III.


RESULTS
Compliance rates were not significantly influenced with CME (intervention I) compared with baseline behavior (54.5% vs 54.4%, P = 0.9140). Significant improvement occurred during the time period when CME was paired with performance data (intervention II) compared with intervention I (59.2% vs 54.4%, P = 0.0002). Further significant improvement occurred when data alone were presented (intervention III) compared with intervention II (65.1% vs 59.2%, P < 0.0001). For patients with 3 risk factors, we saw significant improvement in compliance rates during intervention III (P = 0.0002). In post hoc analysis of overtreatment, the percentage differences between the baseline and time period III decreased as the number of risk factors increased.


CONCLUSIONS
We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.
M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Mail Stop 409, Houston, TX 77030, USA. jfrenzel@mdanderson.or
John C
JC
Frenzel
Spencer S
SS
Kee
Joe E
JE
Ensor
Bernhard J
BJ
Riedel
Joseph R
JR
Ruiz
D000046:Academic Medical Centers; D000776:Anesthesiology / Q000193:education / Q000706:statistics & numerical data*; D000932:Antiemetics / Q000627:therapeutic use*; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D002983:Clinical Competence / Q000706:statistics & numerical data*; D004359:Drug Therapy, Combination; D004502:Education, Medical, Continuing / Q000706:statistics & numerical data*; D004650:Employee Performance Appraisal / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D030141:Feedback, Psychological; D019983:Guideline Adherence; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D016014:Linear Models; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D020250:Postoperative Nausea and Vomiting / Q000209:etiology / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016730:Program Development; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome
D000932:Antiemetics