Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya

Abstract

BackgroundAudit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of A&F delivered as part of a wider set of activities to promote paediatric guideline adherence.MethodsWe analysed data collected from medical records on discharge for children aged 2–59 months from 14 Kenyan hospitals in the CIN. Hospitals joined CIN in phases and for each we analysed their initial 25 months of participation that occurred between December 2013 and March 2016. A total of 34 indicators of adherence to recommendations were selected for evaluation each classified by form of feedback (passive, active and none) and type of task (simple or difficult documentation and those requiring cognitive work). Performance change was explored graphically and using generalised linear mixed models with attention given to the effects of time and use of a standardised paediatric admission record (PAR) form.ResultsData from 60 214 admissions were eligible for analysis. Adherence to recommendations across hospitals significantly improved for 24/34 indicators. Improvements were not obviously related to nature of feedback, may be related to task type and were related to PAR use in the case of documentation indicators. There was, however, marked variability in adoption and adherence to recommended practices across sites and indicators. Hospital-specific factors, low baseline performance and specific contextual changes appeared to influence the magnitude of change in specific cases.ConclusionOur observational data suggest some change in multiple indicators of adherence to recommendations (aspects of quality of care) can be achieved in low-resource hospitals using A&F and simple job aides in the context of a wider network approach.

Pentavalent vaccination in rural Kenya: coverage and geographical accessibility to health facilities using data from a community demographic and health surveillance system in Kilifi County.

“…This further demonstrates the value addition to immunization coverage that CHVs' involvement in child immunization services can offer. In this study, the use of CHVs, coupled with integrated audit and feedback activities embedded in the community by the CHVs, improved the overall adoption of recommended immunization practices over time [48]. We posit that engaging CHVs in regular data collection in the households provided for increased contact with household members, which afforded them opportunities for enhanced health education and promotion, including tracing defaulters of essential health services such as vaccinations.…”

Using rubber stamps and mobile phones to help understand and change antibiotic prescribing behaviour in private sector primary healthcare clinics in Kenya

“…Since ‘ideal’ prescribing rates are likely to vary by infectious condition,35 36 surveillance using prescription or sales data alone (without information on diagnosis or documentation on the need for antibiotics) may hide differences in case mix and context of care. Routine data on primary care delivery, combined with audit and feedback, also has the advantage of being actionable at facility level,37 38 and presents a powerful and widely studied and used tool to affect clinician practices 13. This study argues for a similar approach to combat global AMR in LMICs.…”

“…Provider training and/or clinical decision support (CDS) systems could close knowledge gaps,12 but overcoming barriers of attitude or behaviour may require investment in quality improvement (QI) efforts through routine audit and feedback strategies 13 14. Routine data on the management of common infectious diseases can provide rich insights into the problem of antibiotic overuse in primary care settings, but in LMIC settings such data are difficult to collect,15 and efforts to link routine data to regular audit and feedback cycles are rare 13. Furthermore, the private sector is playing an increasingly vital role in healthcare delivery in LMICs but with little support for systematic QI across a fragmented healthcare market 16 17.…”

Handling missing data in a composite outcome with partially observed components: Application in clustered paediatric routine data.

“…From preliminary analysis, missing data in pneumonia care processes varied within and between PAQC score domains. The rate of missingness could be explained by complexity underlying individual tasks [44]. That is, care processes (PAQC subcomponents) perceived to require more cognitive effort (e.g.…”