title: Improving emergency physician performance using audit and feedback: a systematic review.
abstract: BACKGROUND
  Audit and feedback can decrease variation and improve the quality of care in a variety of health care settings. There is a growing literature on audit and feedback in the emergency department (ED) setting. Because most studies have been small and not focused on a single clinical process, systematic assessment could determine the effectiveness of audit and feedback interventions in the ED and which specific characteristics improve the quality of emergency care.
  
  
  OBJECTIVE
  The objective of the study is to assess the effect of audit and feedback on emergency physician performance and identify features critical to success.
  
  
  METHODS
  We adhered to the PRISMA statement to conduct a systematic review of the literature from January 1994 to January 2014 related to audit and feedback of physicians in the ED. We searched Medline, EMBASE, PsycINFO, and PubMed databases. We included studies that were conducted in the ED and reported quantitative outcomes with interventions using both audit and feedback. For included studies, 2 reviewers independently assessed methodological quality using the validated Downs and Black checklist for nonrandomized studies. Treatment effect and heterogeneity were to be reported via meta-analysis and the I2 inconsistency index.
  
  
  RESULTS
  The search yielded 4332 articles, all of which underwent title review; 780 abstracts and 131 full-text articles were reviewed. Of these, 24 studies met inclusion criteria with an average Downs and Black score of 15.6 of 30 (range, 6-22). Improved performance was reported in 23 of the 24 studies. Six studies reported sufficient outcome data to conduct summary analysis. Pooled data from studies that included 41,124 patients yielded an average treatment effect among physicians of 36% (SD, 16%) with high heterogeneity (I2=83%).
  
  
  CONCLUSIONS
  The literature on audit and feedback in the ED reports positive results for interventions across numerous clinical conditions but without standardized reporting sufficient for meta-analysis. Characteristics of audit and feedback interventions that were used in a majority of studies were feedback that targeted errors of omission and that was explicit with measurable instruction and a plan for change delivered in the clinical setting greater than 1 week after the audited performance using a combination of media and types at both the individual and group levels. Future work should use standardized reporting to identify the specific aspects of audit or feedback that drive effectiveness in the ED.
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
authors: R
authors: R
authors: Le Grand Rogers
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
authors: Yizza
authors: Y
authors: Narvaez
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT.
authors: Arjun K
authors: AK
authors: Venkatesh
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Robert Wood Johnson Clinical Scholar Program, Yale School of Medicine, New Haven, CT.
authors: William
authors: W
authors: Fleischman
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
authors: M Kennedy
authors: MK
authors: Hall
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
authors: R Andrew
authors: RA
authors: Taylor
authors: Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT.
authors: Denise
authors: D
authors: Hersey
authors: Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT.
authors: Lynn
authors: L
authors: Sette
authors: Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
authors: Edward R
authors: ER
authors: Melnick
mesh_terms: D004636:Emergency Service, Hospital / Q000592:standards*; D005246:Feedback; D006801:Humans; D008485:Medical Audit; D008505:Medical Staff, Hospital / Q000592:standards*; D017063:Outcome Assessment, Health Care