title: Feedback GAP: pragmatic, cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care.
abstract: BACKGROUND
  Audit and feedback to physicians is a commonly used quality improvement strategy, but its optimal design is unknown. This trial tested the effects of a theory-informed worksheet to facilitate goal setting and action planning, appended to feedback reports on chronic disease management, compared to feedback reports provided without these worksheets.
  
  
  METHODS
  A two-arm pragmatic cluster randomized trial was conducted, with allocation at the level of primary care clinics. Participants were family physicians who contributed data from their electronic medical records. The 'usual feedback' arm received feedback every six months for two years regarding the proportion of their patients meeting quality targets for diabetes and/or ischemic heart disease. The intervention arm received these same reports plus a worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Blood pressure (BP) and low-density lipoprotein cholesterol (LDL) values were compared after two years as the primary outcomes. Process outcomes measured the proportion of guideline-recommended actions (e.g., testing and prescribing) conducted within the appropriate timeframe. Intention-to-treat analysis was performed.
  
  
  RESULTS
  Outcomes were similar across groups at baseline. Final analysis included 20 physicians from seven clinics and 1,832 patients in the intervention arm (15% loss to follow up) and 29 physicians from seven clinics and 2,223 patients in the usual feedback arm (10% loss to follow up). Ten of 20 physicians completed the worksheet at least once during the study. Mean BP was 128/72 in the feedback plus worksheet arm and 128/73 in the feedback alone arm, while LDL was 2.1 and 2.0, respectively. Thus, no significant differences were observed across groups in the primary outcomes, but mean haemoglobin A1c was lower in the feedback plus worksheet arm (7.2% versus 7.4%, p<0.001). Improvements in both arms were noted over time for one-half of the process outcomes.
  
  
  CONCLUSIONS
  Appending a theory-informed goal setting and action planning worksheet to an externally produced audit and feedback intervention did not lead to improvements in patient outcomes. The results may be explained in part by passive dissemination of the worksheet leading to inadequate engagement with the intervention.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT00996645.
authors.affiliation: Department of Family and Community Medicine, Women's College Hospital, 76 Grenville Street, Toronto, ON M5S 1B2, Canada. noah.ivers@utoronto.ca.
authors.forename: Noah M
authors.initials: NM
authors.lastname: Ivers
authors.forename: Karen
authors.initials: K
authors.lastname: Tu
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Young
authors.forename: Jill J
authors.initials: JJ
authors.lastname: Francis
authors.forename: Jan
authors.initials: J
authors.lastname: Barnsley
authors.forename: Baiju R
authors.initials: BR
authors.lastname: Shah
authors.forename: Ross E
authors.initials: RE
authors.lastname: Upshur
authors.forename: Rahim
authors.initials: R
authors.lastname: Moineddin
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
mesh_terms: D001794:Blood Pressure; D008078:Cholesterol, LDL / Q000097:blood; D002908:Chronic Disease / Q000628:therapy; D016000:Cluster Analysis; D005246:Feedback; D006040:Goals; D006801:Humans; D008485:Medical Audit; D009864:Ontario; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care; D011785:Quality Assurance, Health Care / Q000592:standards; D058996:Quality Improvement
chemical_list: D008078:Cholesterol, LDL