PDF(Pubmed)
Abstract：
BACKGROUND: Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.
METHODS: Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.
RESULTS: The program\'s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.
CONCLUSIONS: Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.
METHODS: Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.
RESULTS: The program\'s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.
CONCLUSIONS: Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.
摘要：
背景：医院护理中不必要的临床差异包括使用不足，过度使用,或滥用服务。审计和反馈是减少不必要变化的常见策略，但它的有效性在不同的背景下差异很大。我们旨在确定实施策略，机制,和上下文环境有助于审核和反馈对不必要的临床变异的影响。
方法：现实主义者研究了2017年至2021年在新南威尔士州实施的全州基于价值的医疗保健计划，澳大利亚。该计划中的三项举措包括审计和反馈，以减少不同条件下住院护理的不必要差异。使用多个数据源来制定初始审计和反馈程序理论：系统回顾，现实主义审查，程序文件审查，以及与关键项目利益相关者的非正式讨论。然后对56名参与者进行了半结构化访谈，以反驳，精炼,或确认最初的程序理论。使用上下文机制结果框架对11份转录本进行回顾性分析，这些转录本被编码到审计和反馈程序理论中。程序理论得到了三个专家小组的验证：高级卫生领导人(n=19)，临床创新机构（n=11），和卫生部（n=21）工作人员。
结果：该计划的审计和反馈实施策略通过八个机械过程进行。当临床医生(1)感受到所有权和买入时，该策略运作良好，(2)能够理解所提供的信息，(3)受社会影响的动机，(4)接受对拟议变更的责任和问责。当审计过程导致（5）使当前实践合理化而不是创造学习机会时，策略的成功受到限制，(6)对不公平的看法和对数据完整性的担忧，7)制定未遵循的改进计划，(8)对专业自主权的感知侵入。
结论：审计和反馈策略可能有助于减少在审计师和当地临床医生之间有接触的护理中不必要的临床差异，有意义的审计指标，明确的改进计划,尊重临床专业知识。通过提出规模审计和反馈实施模型，我们为审计和反馈做出了理论发展。建议包括限制审计指标的数量,让临床工作人员和当地领导参与反馈，并提供反思的机会。
方法：现实主义者研究了2017年至2021年在新南威尔士州实施的全州基于价值的医疗保健计划，澳大利亚。该计划中的三项举措包括审计和反馈，以减少不同条件下住院护理的不必要差异。使用多个数据源来制定初始审计和反馈程序理论：系统回顾，现实主义审查，程序文件审查，以及与关键项目利益相关者的非正式讨论。然后对56名参与者进行了半结构化访谈，以反驳，精炼,或确认最初的程序理论。使用上下文机制结果框架对11份转录本进行回顾性分析，这些转录本被编码到审计和反馈程序理论中。程序理论得到了三个专家小组的验证：高级卫生领导人(n=19)，临床创新机构（n=11），和卫生部（n=21）工作人员。
结果：该计划的审计和反馈实施策略通过八个机械过程进行。当临床医生(1)感受到所有权和买入时，该策略运作良好，(2)能够理解所提供的信息，(3)受社会影响的动机，(4)接受对拟议变更的责任和问责。当审计过程导致（5）使当前实践合理化而不是创造学习机会时，策略的成功受到限制，(6)对不公平的看法和对数据完整性的担忧，7)制定未遵循的改进计划，(8)对专业自主权的感知侵入。
结论：审计和反馈策略可能有助于减少在审计师和当地临床医生之间有接触的护理中不必要的临床差异，有意义的审计指标，明确的改进计划,尊重临床专业知识。通过提出规模审计和反馈实施模型，我们为审计和反馈做出了理论发展。建议包括限制审计指标的数量,让临床工作人员和当地领导参与反馈，并提供反思的机会。
