Audit and Feedback for Primary Care: a Cluster-randomized Trial
Audit and Feedback for Primary Care: a Cluster-randomized Trial
In a previous study, the investigators delivered graphs to family physicians that outlined
 the proportion of patients with a history of diabetes or heart disease achieving
 evidence-based quality targets derived from guideline recommendations. A qualitative
 evaluation found that participating family physicians did not act upon the feedback for two
 main reasons. First, they felt that targets recommended in guidelines often did not apply for
 particular patients. Second, they complained that had difficulty using the feedback reports
 that only provided aggregate level data for clinical action. In this cluster-randomized
 trial, the investigators test two approaches to conducting audit and feedback that aims to
 address these issues. The investigators hypothesize that feedback identifying a small number
 of patients at high-risk for cardiovascular events requiring action will more effectively
 lead to changes in clinical behavior than feedback identifying all patients not reaching
 optimal care targets.
For the last two years, all physicians contributing data to the Electronic Medical Record
 Administrative data Linked Database (EMRALD) have received two feedback reports. The first
 focused on diabetes and the second on patients with heart disease. The reports provide
 aggregate information regarding the proportion of the family physician's patients meeting
 quality targets, but no patient-specific information. Currently the feedback is sent to
 physicians by courier from the EMRALD team every six months.

 The intervention arms in this trial are as follows:

 -  Arm 1 - Standard, aggregate-level feedback reports focusing on the proportion of
 patients with hypertension and/or diabetes and/or ischemic heart disease meeting targets
 sent via courier every six months and available on a password protected website. Family
 physicians in this arm will also have access through this website to patient-level data
 to identify patients not achieving optimal quality of care targets.

 -  Arm 2 - Aggregate-level feedback reports focusing on the proportion of patients with
 hypertension and/or diabetes and/or ischemic heart disease meeting criteria for
 high-risk sent via courier every six months and available on a password protected
 website. Family physicians in this arm will also have access through this website to a
 list of chart numbers identifying those patients at highest risk.

 Both arms will have the opportunity to receive continuing medical education credits by
 completing worksheets that prompt them to reflect upon the data. Family physicians in Arm 1
 are asked to complete a worksheet that follows continuous quality improvement principles,
 including setting an aim statement, engagement with team members in the clinic, testing
 change concepts at first on a small scale, and then scaling up in a effort to spread best
 practices. Family physicians in Arm 2 are asked to complete a worksheet that also includes
 goal setting and action planning, but focuses on reducing the number of patients with
 high-risk criteria and offers some suggested practice-based approaches.
Inclusion Criteria:

 -  Family physicians belonging to and sharing data with the Electronic Medical Record
 Administrative Linked Database in Ontario

 -  Patients rostered to these family physicians with diabetes or hypertension or ischemic
 heart disease

 Exclusion Criteria:

 -  Family physicians without at least two years of Electronic Medical Record data in
 EMRALD

 -  Family physicians without at least 100 rostered, active patients