Kiefe 2001
| Methods | Purpose: to compare a multimodal improvement intervention with chart review and feedback to physicians, to the same intervention plus feedback about the performance of the top 10% of physicians Design: RCT, physicians randomly assigned; 20 records for each physician randomly assessed at baseline and a different set of 20 records at follow‐up Duration of study: baseline was performance of physicians 1 January 1994 through 30 June 1995; intervention during 1996; follow‐up through 30 June 1998 Interval between intervention and when outcome was measured: 1 January 1997 to 30 June 1998 Power computation: (E‐mail from author Dr. C Kiefe; "We did perform an a priori power computation to have at least 80% power to detect an effect on at least one of the indicators. Because the study was positive, this became meaningless and we did not include this is the paper.") Statistics: t tests; generalised linear models with nesting of participants within physicians and controlling for baseline performance (no adjustments for patient characteristics as "each quality measure specified a group of participants who were ideal candidates for intervention") | |
| Participants | Country: USA Setting: 561 eligible physicians in Alabama Eligible participants: (health status) random sample of 97 Alabama fee‐for‐service physicians (of whom 70 completed the study; the 27 who did not complete the study practised in a different environment, or were retired or deceased) from a group of 561 Alabama family physicians, internists and endocrinologists. The 70 physicians had 2978 diabetic participants. Exclusions were: end‐stage renal disease, in a skilled nursing home, dead at baseline. (E‐mail from author Dr C Kiefe: "Community physicians who were participating in CMS (then [Alabama Health Quality Assurance Foundation] HCFA) Ambulatory Care Quality Improvement Project (ACQIP). The analyses were at the patient level, because the outcomes were measured at the patient level. Patients were Medicare beneficiaries with diabetes.") Age: average age 76 Gender: not stated; ("We have archived the original data and we could find the exact % female, but it would be fairly burdensome. I seem to remember that this older Medicare population had about 75% women") | |
| Interventions | Intervention 1: Ambulatory Care Quality Improvement Project; physicians given performance feedback on diabetes care, then quality improvement (n = 49 physicians, 14 lost to follow‐up) Intervention 2: same as 1 + achievable benchmark based on performance of top 10% of physicians being assessed (n = 48 physicians, 13 lost to follow‐up) No control group | |
| Outcomes | Outcome measured: % influenza vaccination Time points from the study that are considered in the review or measured or reported in the study: baseline was performance of physicians 1 January 1994 through 30 June 1995; intervention during 1996; follow‐up 1 January 1997 to 30 June 1998 % vaccinated by: 20 June 1998 | |
| Notes | Funding: Agency for Health Care Research and Quality | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "... this group‐randomized trial"; (E‐mail from author Dr. C Kiefe: "We randomised the physicians and then reviewed the medical records of their participants to ascertain whether flu vaccine was documented.") |
| Allocation concealment (selection bias) | Unclear risk | No statement |
| Blinding (performance bias and detection bias) All outcomes | Unclear risk | No statement, but vaccination status assessed by chart review using protocol tested by pilot |
| Incomplete outcome data (attrition bias) All outcomes | High risk | Outcomes for physicians who did not complete study not presented. E‐mail from author Dr. C Kiefe: ("It was not possible to review records for physicians who no longer wished to participate or were lost to follow‐up.") |
| Selective reporting (reporting bias) | Low risk | No selective reporting |