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Physician feedback enhances quality of care Providing physicians with feedback on standards of excellence achieved by top performers in their peer groups can significantly enhance the effectiveness of interventions to improve the quality of care, according to an article in a recent issue of The Journal of the American Medical Association (JAMA).    Catarina I. Kiefe, Ph.D., M.D., and colleagues with the University of Alabama at Birmingham conducted a randomized controlled trial (RCT) to evaluate the effectiveness of using achievable benchmarks to enhance typical physician performance feedback and improve care.     The trial included 70 community physicians and 2,978 fee-for-service Medicare patients with diabetes mellitus who were part of the Ambulatory Care Quality Improvement Project in Alabama.   According to background information cited in the article, there are large and widespread gaps between medical care as actually practiced and the recommendations derived from evidence-based research. Performance feedback and benchmarking, common tools for health care improvement, are rarely studied in randomized trials. Achievable benchmarks are standards of excellence of medical care attained by top performers in a peer group and are easily and reproducibly calculated from existing performance data.   The achievable benchmark represents the average performance for the top 10 percent of the physicians being assessed. In practice, adjustments are made to account for differences in the numbers of patients per physician and also to allow for the inclusion of physicians with small numbers of eligible patients without unduly distorting the overall performance assessment.   In the trial conducted in December 1996, with follow-up through 1998, 35 physicians designated as the comparison group were randomly assigned to receive an improvement intervention, including chart review and physician-specific feedback. The other 35 physicians, designated as the experimental group, were assigned an identical intervention plus achievable benchmark feedback. The authors noted changes from before (1994-1995) to after the intervention (1997-1998) in the proportion of patients with diabetes receiving influenza vaccination, foot examination, and each of three blood tests measuring glucose control, cholesterol, and triglyceride level. The changes were compared between the two groups.   “For influenza vaccination, foot examination, and long-term glucose control measurement, physician receipt of achievable benchmark feedback was associated with 33 percent to 57 percent higher odds of patients receiving appropriate care at follow-up compared with patients of comparison physicians,” the authors write.   “The proportion of patients who received influenza vaccine improved from 40 percent to 58 percent in the experimental group vs. from 40 percent to 46 percent in the comparison group,” they report. “In addition, both experimental and comparison groups improved significantly on foot examination (46 percent to 61 percent vs. 32 percent to 45 percent) and long-term glucose control measurement (31 percent to 70 percent vs. 30 percent to 65 percent).”   The experimental group improved significantly for cholesterol measurement (66 percent to 72 percent), while the comparison group did not (66 percent to 69 percent). The changes for triglyceride measurement were not significant (61 percent to 65 percent vs. 57 percent to 60 percent).   The authors adjusted their findings for physician characteristics, including practice location (urban, suburban, rural), year of graduation from medical school, and specialty (family practice, internal medicine, etc.). “Even after adjustment for multiple physician characteristics, patients of physicians assigned to the experimental study arm had significantly higher odds of receiving appropriate care at follow-up on all five measures,” they write.   The authors believe the achievable benchmark method offers a simple, new quality improvement tool for translating evidence into practice. “In the RCT reported here, we have demonstrated this tool’s effectiveness in enhancing audit and feedback based on medical record review in the ambulatory setting,” they write.  “With the current imperative to improve health care delivery, any effective addition to improvement efforts deserves close attention.”