title: Analyzing effects of providing performance feedback at ward rounds on guideline adherence - the importance of feedback usage analysis and statistical control charts.
abstract: OBJECTIVE
  Feedback to clinicians on their past performance is often aimed at increasing adherence to guidelines. We investigate how various analytical approaches influence the interpretation of adherence data. The analytical approaches vary in considering the actual or the intended use of the feedback, and whether outcomes are inspected over time.
  
  
  METHODS
  At base line, a computerized decision support system was employed at the ICU bedside to increase adherence to a mechanical ventilation strategy. We intervened by providing feedback about adherence to the guideline at the daily ward rounds. The outcome measure was the percentage of ventilation time (V<inf>T</inf>) in excess of the guideline's recommendation. Actual usage of the feedback was logged and data analysis was carried out using two approaches: classical statistics, and statistical process control (SPC) that inspect progress of an outcome over time.
  
  
  METHODS
  Prospective, before/after study.
  
  
  RESULTS
  The classical analysis stated that the percentage of ventilation time in excess of the guideline's recommendation decreased significantly due to the feedback (5% reduction, p < 0.001). When SPC analysis of the outcome was applied, the effect was deemed not significant. When the actual delivery of feedback over time was also included it showed that the experiment does not allow for conclusive results.
  
  
  CONCLUSIONS
  The concluded effect of providing feedback on adherence to a guideline depends on whether the actual usage pattern of the feedback and the inspection of the outcome over time are considered. Future evaluative studies should report on usage patterns and progression of outcomes over time.
authors.affiliation: Department of Medical Informatics, University of Amsterdam, Amsterdam, The Netherlands. a.abu-hanna@amc.uva.nl
authors.forename: Ameen
authors.initials: A
authors.lastname: Abu-Hanna
authors.forename: Saeid
authors.initials: S
authors.lastname: Eslami
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.forename: Evert
authors.initials: E
authors.lastname: de Jonge
authors.forename: Nicolette F
authors.initials: NF
authors.lastname: de Keizer
mesh_terms: D020000:Decision Support Systems, Clinical; D005246:Feedback; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006761:Hospitals; D006801:Humans; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012107:Research Design; D012121:Respiration, Artificial / Q000379:methods; D013990:Tidal Volume