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