Meta-analysis: audit and feedback features impact effectiveness on care quality

Med Care. 2009 Mar;47(3):356-63. doi: 10.1097/MLR.0b013e3181893f6b.


Background: Audit and feedback (A&F) has long been used to improve quality of care, albeit with variable results. This meta-analytic study tested whether Feedback Intervention Theory, a framework from industrial/organizational psychology, explains the observed variability in health care A&F research.

Data source: studies cited by Jamtvedt's 2006 Cochrane systematic review of A&F, followed by database searches using the Cochrane review's search strategy to identify more recent studies.

Inclusion criteria: Cochrane review criteria, plus: presence of a treatment group receiving only A & F; a control group receiving no intervention; a quantitatively measurable outcome; minimum n of 10 per arm; sufficient statistics for effect size calculations. Moderators: presence of discouragement and praise; correct solution, attainment level, velocity, frequency, and normative information; feedback format (verbal, textual, graphic, public, computerized, group vs. individual); goal setting activity.

Procedure: meta-analytic procedures using the Hedges-Olkin method.

Results: Of 519 studies initially identified, 19 met all inclusion criteria. Studies were most often excluded due to the lack of a feedback-only arm. A&F has a modest, though significant positive effect on quality outcomes (d = 0.40, 95% confidence interval = +/-0.20); providing specific suggestions for improvement, written, and more frequent feedback strengthened this effect, whereas graphical and verbal feedback attenuated this effect.

Conclusions: A&F effectiveness is improved when feedback is delivered with specific suggestions for improvement, in writing, and frequently. Other feedback characteristics could also potentially improve effectiveness; however, research with stricter experimental controls is needed to identify the specific feedback characteristics that maximize its effectiveness.

Publication types

  • Meta-Analysis
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Review
  • Systematic Review

MeSH terms

  • Feedback*
  • Health Services Research*
  • Humans
  • Medical Audit*
  • Psychology, Industrial
  • Quality Assurance, Health Care*
  • Randomized Controlled Trials as Topic