a systematic review of a&f interventions: the good, the bad, and the ugly heather colquhoun,...
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A Systematic Review of A&F interventions: the good, the bad, and the uglyHeather Colquhoun, CIHR and KT Canada Postdoctoral Fellow, OHRI
Research Team
Jamie C Brehaut, Ottawa Hospital Research Institute (OHRI)
Kevin Eva, University of British Columbia (Vancouver)
Jeremy Grimshaw, OHRI
Anne Sales, University of Michigan (Ann Arbor)
Noah Ivers, Women’s College Research Institute (Toronto)
Susan Michie, University College London (UK)
Heather Colquhoun, OHRI
Kelly Carroll, MSc, OHRI
Mathieu Chalifoux, OHRI
Funding: CIHR KT Priority Announcement
Systematic Review of studies of A&F
• Not focused on effectiveness, but rather the details of the interventions• Extent, type and purpose of theory use• Consistency with theoretical constructs believed to
be important for A&F• Intervention description
Methods
• Systematic Review• 140 RCT’s of A&F from the Cochrane Review• Data extraction form, pilot X 2• Extracted by two reviewers, one consistent• Separate extraction with consensus for disagreements
A&F Interventions
• To whom?• What exactly? • Where and how delivered?• How much?• Why?
• Give results, challenges, examples of variations
To whom?
• Was the FB given to the person in whom the behaviour change was desired?
Who was FB given to? Count (%)
Individual 72 (51%)
Group 25 (18%)
Individual and Group 23 (16%)
Unclear 20 (14%)
Yes No Unclear
130 (92%) 6 (5%) 4 (3%)
What exactly?FB about Yes No Unclear
Behaviour 111 (79%) 9 (6%) 20 (15%)
Outcomes 20 (14%) 102 (73%) 18 (13%)
Other 45 (32%) 95 (68%) n/a
Individuals Performance
81 (58%) 50 (36%) 9 (6%)
Groups Performance
90 (64%) 38 (27%) 12 (9%)
Aggregate data 114 (81%) 15 (11%) 11 (8%)
Individual data 35 (25%) 95 (68%) 10 (7%)
What exactly?
• Feedback about ‘Other’ 45 (32%)• Accuracy of their diagnosis• Cost• Risk data for patients (stroke, infection)• Education as FB (FB on what type of antibiotic they
should have prescribed) • Survey on barriers to change
What exactly?
• Was the FB graphical?
• Did the FB address the behaviour to be changed?
• Was there a clear comparison in the FB?
Yes No Unclear
124 (89%) 9 (6%) 7 (5%)
Yes No Unclear
47 (36%) 73 (52%) 20 (14%)
Yes No
104 (74%) 36 (26%)
Comparison for A&F
Other: internal standard, “plan wide scores” for comparison, systematic review, algorithm,
others previous performance + thresholds set by expert panel, others previous
performance + own previous performance + drug formulations that accounted for >60%
of charges + the total charges
How delivered?
• Was the FB given face to face?
Yes No Unclear
62 (44%) 68 (49%) 10 (7%)
How much – Total feedback
• Unclear: 33 (24%)• Clear: 107 (76%)
• Once: 33• Twice: 21• Three times: 13• Four times: 13• >four times: 27 (range 5-78)
• Frequency• Challenges
When and how much?
• Was the lag time between collection of the FB and the provision of the FB clearly stated?
• If yes, what was it?• Days: 6• Weeks: 23• Months: 56• Years: 1• Mix: 2
Yes No
88 (63%) 52 (37%)
Why A&F?Intervention rationale in A&F trials
Rationale for intervention Count (%)N=140
Empirical (only) 51 (36%)
Intuitive 39 (28%)
No rationale 37 (26%)
Theory 13 (9%)
Reporting
• “The data was presented in an easy to follow format”• “Extensive feedback was provided twice a week”• “Feedback was always discussed in detail”• “The exact nature of the A&F was decided within each
audit group and supported by the researcher with help and advice from the tutor”
Hospital Report Card: Given to individuals not given to target, about behaviour, about the group, aggregate, comparison: multiple, given 1X, 12 indicators
Given to individuals (mailed), individual and group performance, aggregate data, multiple comparison, target yes, behaviour yes, key message, every 2 months for 6 months (3)
Given to individuals, individual
performance?, ind data,
target yes, behaviour no, monthly for 9
months
Self-monitoring, face to face,
given to individual, individual
performance, weekly for 4
months?
“To be displayed in a conspicuous
location in their office”
Summary
• Some consistency but also wide variation• Reporting is poor in many areas• Rationale for the intervention is lacking
Thank you
Given to individuals by mail, individual and group performance, multiple comparisons, quarterly for 18 months (6), target yes, behaviour yes
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