Background: Theory-based implementation strategies, such as audit and feedback (A&F), can improve the adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute cardiovascular disease (CVD) risk reduction protocols, but A&F strategies to support them are not well examined. Our objective was to develop and evaluate a theory-based approach to A&F, Interactive and Participatory A&F (IPAF).
Methods: We developed IPAF informed by two complementary theories, self-regulation theory (SRT) and self-determination theory (SDT). IPAF applies concepts from these theories to inform (1) what to address with staff to improve rates of best practices (SRT) and (2) how to interact with staff to improve behaviors aligned with best practices (SDT). We promoted IPAF fidelity by developing a semi-structured guide to facilitate staff discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a hybrid type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, appropriateness, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including electronic health record (EHR) data, team records, and staff questionnaire responses.
Results: Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or phone) IPAF sessions during the first 6 months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90-93%) and engagement in IPAF sessions. Staff highly rated questionnaire items about IPAF acceptability. Team records and staff responses demonstrated fidelity of IPAF delivery and receipt. Adoption of target behaviors increased significantly (all P values < 0.05), and adoption or behaviors were maintained for over 24 months.
Conclusions: We developed and evaluated a theory-based approach to A&F with frontline staff in specialty clinics to improve the implementation of evidence-based interventions. The findings support feasibility, appropriateness, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we extended prior research on clinic protocols and A&F beyond primary care settings and providers.
Keywords: Audit and feedback; Cardiovascular disease; Effectiveness-implementation hybrid; Frontline staff; Implementation outcomes; Implementation strategies; Medical assistants; Preventive care; Specialty clinics; Theory-based strategies.