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Table 3 Summary of quality improvement projects

From: Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Almohiza2016US15 outpatient neurological speciality clinics23 physical therapistsReported a 16-week quality improvement project amongst physical therapists working in rehabilitation services in the US. A clinical treatment algorithm was developed to determine evidence-based effective practices and deviation from these was considered ‘non-compliant’, indicating problematic variation. Following a behavioural intervention program including a webinar, test and competency training, adherence to the processes identified as effective by the clinical algorithm was assessed and improved by 5–10%. Over utilised treatments reduced by 16% post-intervention.
Baker2008USCardiac Surgery Research database979 cardio-pulmonary bypass patientsReported findings of a project to reduce variation in the care process for cardiac surgical patients that compared no QI data with automated QI data alone and automated QI data with implementation of a continuous quality improvement project. This study pulls together the use of health information technology, quality reporting and improvement interventions. Adherence to protocol and reduction in practice variation was enhanced in the automated feedback programme but optimised by the use of a CQI approach.
Caterson2015US1 tertiary hospitalImpact-based reconstruction (methodological work)Reported the development and use of a Standardised Clinical Assessment and Management Plan (SCAMP) in plastic surgery with a decision-tree algorithm. Adherence to the SCAMP algorithm was used to identify variation and direct quality improvement efforts to address this.
Deyo2000US22 health organisations including 12 hospitals, insurance plans, multicentred health services and independent services.3 team members from each of the 22 organisationsMeasurement and education program with 22 participating organisations including health plans and medical centres. Those organisations and service with “outlier” rates of imaging or referral (identified as statistical outliers from the normal range of imaging or referral in each organisation) were used to identify clinics or physicians for targeted intervention. The intervention program including three learning sessions, focusing on areas of practice variation identified by the participating organisations from their own data, in addition to a final national congress. Participants worked within their own teams to problem-solve and then across teams from other organisations. A key component of the process was to present their clinical variation data and perform continuous repeated measurements to track change in variations. Findings suggest that the approach was effective in reducing unwarranted variations, although outcome measures used to assess variation were different across the participating sites based on their clinical goals and data sources. Reduced variations were identified in outcomes such as levels of x-rays ordered, prescribed bed-rest and also increased the use of patient education materials by 100% that may also work to address unwarranted variations
Dorfsman2018US3 emergency medicine programs in academic health centres31 residentsUtilised variations from guideline-based care in the organisation’s emergency medicine to develop educational sessions for residents working in that department on a monthly basis. The sessions explored the evidence base for a particular practice and variation, expert discussions on areas in which the evidence base was not conclusive regarding effective care and encouraged debates between residents attending [54]. Findings did not establish whether the training addressed unwarranted variations or changed behaviour, but 77% of the 31 residents surveyed indicated that the sessions aided their understanding of why clinical practice variations may occur
Dykes2005US1 community hospitalPre-test sample - 90 heart failure patients over 65 and 55 control stroke patients over 65. Post-test sample - 96 heart failure patients over 65 and 75 control stroke patients over 65Incorporated an automated care pathway in the electronic medical record into an intervention that included evidence provision to clinicians and patients, a self-management tool and discipline-specific feedback regarding guideline adherence to enhance care for stroke patients. The study reported that point of care evidence enhances adherence to guidelines including those around patient self-management education in stroke care.
Griffiths2017UKRoyal College of PathologistsTraining event and grand rounds resulted in 50 checklists completed - no data re attendance of these.Key performance indicators were used to identify variations in individual practice and report this back alongside a quality improvement project. The project included implementing four checklists based on evidence-based guidelines along with a weekly training event to try to reduce variations in pathology practices. The project isolated the effect of the intervention from the training component and established that utilising a checklist alone was associated with conforming to the evidence-based approach rather than the addition of the training component. Having the checklist available at the point of dissection was critical.
Lee2016USCommunity and specialist inflammatory bowel disease clinics in one health service50 electronic medical charts of 6 gastroenterology fellowsA random selection of medical records was audited against 15 quality measures for inflammatory bowel disease and then re-audited after an educational session in which the quality measures and performance against these was reviewed. Lee at al identified a positive correlation between the intervention and compliance with the quality measures, with compliance increasing by 16%
Miller2011USThree urology practices858 urology presentationsBetween 2009 and 2010, Urological Surgery Quality Collaborative surgeons collected data for men with newly diagnosed prostate cancer through 3 phases of data collection. In phases 2 and 3, collaborative quality improvement interventions, including comparative performance feedback, and review and dissemination of clinical guidelines were used. The use of bone scans and computerized tomography across prostate cancer risk strata, Urological Surgery Quality Collaborative practice locations, and before and after quality improvement interventions was examined.
Nguyen2007US44 facilities in the Northwest Renal Network4 workshops attended by - 36 nephrologists, 16 VA surgeons and 1 radiologist; 35 physicians responded to the follow-up surveyA network education model was reported as a strategy to reduce unwarranted variation in dialysis using arteriovenous fistula (AVF). Forty-six facilities contributed to four targeted regional workshops that explored the root causes of low AVF rates by interviews with vascular surgeons, nephrologists, dialysis staff, and interventional radiologists. The analysis identified three key barriers to a higher AVF rate: 1) Failure of nephrologists to act as vascular access team leaders; 2) Lack of AVF training for vascular access surgeons, including vessel assessment skills, vein mapping, and complex surgical techniques and 3) Late referral of chronic kidney failure (CKF) patients to nephrology. A literature review was then conducted to identify best demonstrated practice regionally and the strategies successfully used by this team were included in the quality improvement project. Four intervention workshop meetings were held and intervention site participants took away follow-up materials to address the content locally. Of the 35 attending physicians, 91% reported that they had changed their practice to address variations based on the intervention in consistent areas relating to AVF use over the five-year period in which outcome data were collected
Nordstrom2016USCohorts of physician practices across Vermont28 physician practices in 4 cohortsReported the impacts of a learning collaborative between 28 physician practices that collected and reported on their quality improvement data through four sessions, in addition to didactic lectures, case presentations and discussion of practice-improvement strategies to reduce variation in the provision of buprenorphine. Findings indicated that there was a substantial reduction of up to 50% in variations across all seven quality measures. A collaborative in urological surgery adopted a facilitated feedback approach with performance feedback and review in relation to clinical guidelines [50]. The authors reported that the urological collaborative demonstrated substantial reductions in variations in practice patterns and guideline adherence following the feedback intervention
Tavender2015UKOne emergency departmentTheoretical workDescribed the process of applying two theoretical frameworks to investigate the factors influencing behaviour and the choice of behaviour change techniques. Two theoretical frameworks were used together to inform intervention development in managing mild traumatic brain injury in the ED. The intervention approach included a range of modes to encourage optimal behaviours in care delivery for managing mild brain trauma.
Tomson2013The NetherlandsReviewReviewLocal level QI projects that engaged a package of clinical actions to achieve the improvement aim were those that saw reductions in problematic variation and enhanced quality. The authors also highlight the inefficiency of a multitude of local level projects and the potential value but also challenges of national or collaborative approaches. A central difficulty identified in this review is the completion of such QI initiatives as an additional activity to routine clinical work.