Factors determining the effectiveness of audit & feedback on clinical guideline adherence of hospital-based medical specialists: a systematic review and meta-analysis of randomized controlled trials

Audit & Feedback (A&F) is a common intervention to enhance clinical guideline adherence, yet uncertainty remains regarding the factors influencing its effectiveness. To examine the effectiveness of A&F interventions targeting clinical guideline adherence of hospital-based medical specialists in general and to determine which design characteristics, co-interventions and contextual factors explain variance in A&F effectiveness. A systematic review and meta-analysis of randomized controlled trials was conducted following the Cochrane Handbook methodology. The electronic databases MEDLINE, Embase and Web of Science were searched up to January 2024. Two reviewers independently screened articles and selected studies on A&F interventions targeting clinical guideline adherence of hospital-based medical specialists. Risk of bias was assessed by two independent reviewers, following the ROB2 tools. Data on design characteristics, co-interventions, contextual factors and outcomes were extracted by one reviewer and checked by a second reviewer. Results were described descriptively and when appropriate meta-analysis and subgroup analyses using random effects modelling was performed. Forty-one studies were included. Studies had a 2-armed ( N = 35), 3-armed ( N = 5) or 2 × 2 ( N = 1) design and compared A&F vs. no intervention ( N = 15), A&F vs. another intervention ( N = 8) or A&F vs. A&F ( N = 20). Studies targeted 23 different medical specialties, of which Cardiology ( N = 8), General Medicine ( N = 7), ICU ( N = 6) and Emergency Care ( N = 6) were most targeted. Risk of bias was low in six studies, with some risk in 19 studies and high risk in 16 studies. Meta-analysis showed a significant improvement of clinical guideline adherence due to A&F, with a pooled OR of 1.30 (95% CI of 1.12–1.50), I 2 = 57.8%, N = 17 comparisons) for A&F vs. no intervention and 1.60 (95% CI 1.38–1.84, I 2 = 8.6%, N = 8 comparisons) for A&F vs. another intervention. Studies examining the effectiveness of A&F interventions showed similar effect sizes, while the variation across studies in types of design characteristics, co-interventions and context was large. Subgroup analyses for design characteristics only showed significant differences if one high risk study was included. Large variation in co-interventions and poor reporting of context factors precluded further subgroup analyses. Within studies there was large variation in effect sizes between different guideline indicators and between different hospitals. A&F showed a positive effect on clinical guideline adherence in medical specialist care, with limited heterogeneity in A&F effectiveness across different studies. Notably, this is the first A&F review to document the within-study variation in A&F effectiveness, emphasizing the influence of clinical topics and context. Furthermore, this review highlights the variability in co-interventions used alongside A&F, underscoring challenges in comparing A&F trials. PROSPERO CRD42021267983.