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Effect of a Multifaceted Performance Feedback Strategy on Length of Stay Compared With Benchmark Reports Alone: A Cluster Randomized Trial in Intensive Care*

van der Veer, Sabine N. MSc1; de Vos, Maartje L. G. MSc2,3; van der Voort, Peter H. J. MD, PhD4; Peek, Niels PhD1; Abu-Hanna, Ameen PhD1; Westert, Gert P. PhD2,5; Graafmans, Wilco C. PhD3; Jager, Kitty J. MD, PhD1; de Keizer, Nicolette F. PhD1

Critical Care Medicine:
doi: 10.1097/CCM.0b013e31828a31ee
Clinical Investigations
Abstract

Objective: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports.

Design: The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011.

Setting: Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months.

Patients: We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded.

Intervention: The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports.

Measurements and Results: The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6–8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0–12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92–1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality).

Conclusions: In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.

Author Information

1Department of Medical Informatics, Academic Medical Centre, Amsterdam, The Netherlands.

2Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, Tilburg, The Netherlands.

3Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.

4Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

5IQ Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands.

*See also p. 2040.

This study was performed at Academic Medical Center, Department of Medical Informatics (Amsterdam, the Netherlands) and University of Tilburg, Scientific Centre for Transformation in Care and Welfare (Tilburg, The Netherlands).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Graafmans is employed by the Ministry of Health, the Netherlands). Dr. de Keizer is a board member with the NICE foundation and his institution received grant support, support for travel, provision of funds for data managers, and support for the development of educational presentations from the NICE foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Trial-Registration: Current Controlled Trials ISRCTN50542146.

For information regarding this article, E-mail: s.n.vanderveer@amc.nl

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins