Interactive and Participatory Audit and Feedback (IPAF): theory-based development and multi-site implementation outcomes with specialty clinic staff

Abstract

Background Theory-based implementation strategies, such as audit and feedback (A&F), can improve the adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute cardiovascular disease (CVD) risk reduction protocols, but A&F strategies to support them are not well examined. Our objective was to develop and evaluate a theory-based approach to A&F, Interactive and Participatory A&F (IPAF). Methods We developed IPAF informed by two complementary theories, self-regulation theory (SRT) and self-determination theory (SDT). IPAF applies concepts from these theories to inform (1) what to address with staff to improve rates of best practices (SRT) and (2) how to interact with staff to improve behaviors aligned with best practices (SDT). We promoted IPAF fidelity by developing a semi-structured guide to facilitate staff discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a hybrid type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, appropriateness, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including electronic health record (EHR) data, team records, and staff questionnaire responses. Results Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or phone) IPAF sessions during the first 6 months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90–93%) and engagement in IPAF sessions. Staff highly rated questionnaire items about IPAF acceptability. Team records and staff responses demonstrated fidelity of IPAF delivery and receipt. Adoption of target behaviors increased significantly (all P values < 0.05), and adoption or behaviors were maintained for over 24 months. Conclusions We developed and evaluated a theory-based approach to A&F with frontline staff in specialty clinics to improve the implementation of evidence-based interventions. The findings support feasibility, appropriateness, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we extended prior research on clinic protocols and A&F beyond primary care settings and providers.

Rheumatology High Blood Pressure Protocol Reduces Disparities, But Delays Remain for External Primary Care

“…In previously published work, we detailed the implementation methodology for BP Connect, which included a focus on rheumatology clinical staff engagement, education, EHR reminders for staff, and staff audit feedback. 5,9 Data Sources Preimplementation and postimplementation EHR data were used to evaluate the timeliness of PC follow-up after rheumatology visits with confirmed BP 140 ≥ 90 mm Hg. Electronic health record index visits were identified in the academic rheumatology clinic EHR (EPIC HealthLink; Epic Systems Corporation, Verona, WI), and timely follow-up was determined through the HMO EHR (EPIC Systems Corporation) using a unique linkage through secure data exchange platforms with institutional review board minimal risk approval.…”

“…In previously published work, we detailed the implementation methodology for BP Connect, which included a focus on rheumatology clinical staff engagement, education, EHR reminders for staff, and staff audit feedback 5,9 …”