دانلود رایگان مقاله انگلیسی بررسی اصولی حسابرسی الکترونیکی و بازخورد ها: استفاده از نظریه تغییر رفتار - NCBI 2017

Abstract

Background: Audit and feedback is a common intervention for supporting clinical behaviour change. Increasingly, health data are available in electronic format. Yet, little is known regarding if and how electronic audit and feedback (e-A&F) improves quality of care in practice. Objective: The study aimed to assess the effectiveness of e-A&F interventions in a primary care and hospital context and to identify theoretical mechanisms of behaviour change underlying these interventions. Methods: In August 2016, we searched five electronic databases, including MEDLINE and EMBASE via Ovid, and the Cochrane Central Register of Controlled Trials for published randomised controlled trials. We included studies that evaluated e-A&F interventions, defined as a summary of clinical performance delivered through an interactive computer interface to healthcare providers. Data on feedback characteristics, underlying theoretical domains, effect size and risk of bias were extracted by two independent review authors, who determined the domains within the Theoretical Domains Framework (TDF). We performed a meta-analysis of e-A&F effectiveness, and a narrative analysis of the nature and patterns of TDF domains and potential links with the intervention effect. Results: We included seven studies comprising of 81,700 patients being cared for by 329 healthcare professionals/ primary care facilities. Given the extremely high heterogeneity of the e-A&F interventions and five studies having a medium or high risk of bias, the average effect was deemed unreliable. Only two studies explicitly used theory to guide intervention design. The most frequent theoretical domains targeted by the e-A&F interventions included ‘knowledge’, ‘social influences’, ‘goals’ and ‘behaviour regulation‘, with each intervention targeting a combination of at least three. None of the interventions addressed the domains ‘social/professional role and identity’ or ‘emotion’. Analyses identified the number of different domains coded in control arm to have the biggest role in heterogeneity in e-A&F effect size. Conclusions: Given the high heterogeneity of identified studies, the effects of e-A&F were found to be highly variable. Additionally, e-A&F interventions tend to implicitly target only a fraction of known theoretical domains, even after omitting domains presumed not to be linked to e-A&F. Also, little evaluation of comparative effectiveness across trial arms was conducted. Future research should seek to further unpack the theoretical domains essential for effective e-A&F in order to better support strategic individual and team goals.

Conclusions

We conclude that although opportunities for electronic A&F are becoming more common, e-A&F randomised interventions are scarce, and from our findings, highly heterogeneous. e-A&F that have been implemented and tested in trials to support performance improvement of clinical practice tend to implicitly target only a fraction of known TDF concepts. This is further compounded by poor assessment of comparative effectiveness of targeted theoretical concepts across trial arms and high risk of bias of the studies.

This is in spite of common theoretical frameworks creating a basis for operationalization of computerised tailoring of A&F for practice behaviour change [21]. Future research should seek to unpack the distinctions between individual and team-based electronic A&F, including issues such as task ownership in addressing personal and team targets, behavioural distinctions in prioritising individual, team and national performance goals, and the influence of professional role, identity and intentions of team members on individual- and team-centric clinical performance goals. Research should also seek to utilise e-A&F capabilities for evaluating of various theoretical concepts in a multi-component interventions using approaches such as AB testing.