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

Abstract

Background: Audit 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.

Methods: We 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.

Results: Data 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.

Conclusion: Our 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.

Keywords: audit and feedback; performance change.; quality improvement indicators.

Figure 1

Cluster-adjusted mean performance (solid lines) at patient level with cluster-adjusted 95% CI (dotted lines) and individual measures of hospitals’ performance (dots) over the first 25 months of a hospital’s engagement with the network (time).

Figure 2

Comparison of documentation performance between the first 3 months (column a) and last 3 months (column b) of network participation for specific indicators (represented as number codes on the y-axis) requiring: simple documentation (upper panel) and difficult documentation (lower panel). Green shading represents excellent performance (>90%), yellow good (80%–90%), pink fair (60%–79%) and red poor (<60%). Upper panel indicator codes: 1: central cyanosis, 2: wheeze, 3: pallor, 4: jaundice, 5: indrawing, 6: acidotic breathing, 7: grunting, 8: thrush, 9: wrist signs for rickets, 10: crackles, 11: stridor, 12: lymph nodes. Lower panel indicator codes: 1: AVPU (alert, verbal response, pain response, unresponsive), 2: skin pinch, 3: can drink, 4: respiratory rate, 5: pulse rate, 6: MUAC/WHZ (mid-upper arm circumference/weight for height z-score), 7: temperature, 8: capillary refill.

Figure 3

Comparison of documentation performance between first 3 months (column a) and last 3 months of network participation (column b) for indicators (represented as number codes on the y-axis) requiring cognitive work to: plan investigations or classify disease severity in line with guidelines (upper panel) and prescribe drugs in compliance with guidelines (lower panel). Upper panel indicator codes: 1: classified dehydration, 2: classified diarrhoea, 3: classified malaria, 4: classified pneumonia, 5: glucose for danger signs, 6: Hb (haemoglobin) for severe pallor, 7: HIV status known, 8: LP (lumbar puncture) results available, 9: MPS (malaria parasite slide) results recorded. Lower panel indicator codes: 1: artesunate for malaria cases, 2: ceftriaxone for meningitis cases, 3: correct gentamicin dose, 4: elevated penicillin dose for meningitis cases, 5: zinc for diarrhoea cases.