Data for improvement and clinical excellence: report of an interrupted time series trial of feedback in long-term care.
BACKGROUND
There is considerable evidence about the effectiveness of audit coupled with feedback for provider behavior change, although few feedback interventions have been conducted in long-term care settings. The primary purpose of the Data for Improvement and Clinical Excellence-Long-Term Care (DICE-LTC) project was to assess the effects of a feedback intervention delivered to all direct care providers on resident outcomes. Our objective in this report is to assess the effect of feedback reporting on rates of pain assessment, depression screening, and falls over time.


METHODS
The intervention consisted of monthly feedback reports delivered to all direct care providers, facility and unit administrators, and support staff, delivered over 13 months in nine LTC units across four facilities. Data for feedback reports came from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated in LTC facilities throughout Alberta. The primary evaluation used an interrupted time series design with a comparison group (units not included in the feedback intervention) and a comparison condition (pressure ulcers). We used segmented regression analysis to assess the effect of the feedback intervention.


RESULTS
The primary outcome of the study, falls, showed little change over the period of the intervention, except for a small increase in the rate of falls during the intervention period. The only outcome that improved during the intervention period was the proportion of residents with high pain scores, which decreased at the beginning of the intervention. The proportion of residents with high depression scores appeared to worsen during the intervention.


CONCLUSIONS
Maintaining all nine units in the study for its 13-month duration was a positive outcome. The feedback reports, without any other intervention included, did not achieve the desired reduction in proportion of falls and elevated depression scores. The survey on intention to change pain assessment practice which was conducted shortly after most of the feedback distribution cycles may have acted as a co-intervention supporting a reduction in pain scores. The processing and delivery of feedback reports could be accomplished at relatively low cost because the data are mandated and could be added to other intervention approaches to support implementation of evidence-based practices.
Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. salesann@umich.edu.|Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, 400 N. Ingalls Street, Ann Arbor, MI, 48109-5482, USA. salesann@umich.edu.
Anne E
AE
Sales
Alberta Health and Wellness, Edmonton, Alberta, Canada. corinne.schalm@gov.ab.ca.
Corinne
C
Schalm
Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. melba.baylon@ualberta.ca.
Melba Andrea B
MA
Baylon
Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. Kimberly.fraser@ualberta.ca.
Kimberly D
KD
Fraser
D000058:Accidental Falls / Q000517:prevention & control; D000416:Alberta; D002983:Clinical Competence / Q000592:standards*; D003866:Depressive Disorder / Q000175:diagnosis; D005246:Feedback; D006282:Health Personnel / Q000592:standards; D006801:Humans; D065186:Interrupted Time Series Analysis; D008134:Long-Term Care / Q000592:standards*; D010146:Pain / Q000517:prevention & control; D010147:Pain Measurement / Q000592:standards; D058996:Quality Improvement / Q000592:standards; D011787:Quality of Health Care / Q000592:standards