Open Access Open Badges Study protocol

Feedback GAP: study protocol for a cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care

Noah M Ivers1234*, Karen Tu245, Jill Francis6, Jan Barnsley3, Baiju Shah237, Ross Upshur2478, Alex Kiss23, Jeremy M Grimshaw9 and Merrick Zwarenstein27

Author Affiliations

1 Women's College Hospital Family Health Team, 76 Grenville Street, Toronto ON, M5 S 1B2, Canada

2 Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto ON, M4N 3M5, Canada

3 Department of Health Policy Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada

4 Department of Family and Community Medicine, University of Toronto, 263 McCaul Street, 5th Floor Toronto ON, M5T 1W7, Canada

5 Toronto Western Hospital Family Health Team, University Health Network, 399 Bathurst Street, West Wing, 2nd Floor, Toronto, ON, M5T 2S8, Canada

6 Health Services Research Unit, University of Aberdeen, Third Floor Health Sciences Building, Foresterhill, Aberdeen, UK

7 Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto ON, M4N 3M5, Canada

8 Joint Centre for Bioethics, University of Toronto, Health Sciences Building, 155 College Street, 7th floor, Toronto, ON, M5T 1P8, Canada

9 Clinical Epidemiology Program, Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa ON, K1Y 4E9, Canada

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Implementation Science 2010, 5:98  doi:10.1186/1748-5908-5-98

Published: 17 December 2010



Audit and feedback to physicians is commonly used alone or as part of multifaceted interventions. While it can play an important role in quality improvement, the optimal design of audit and feedback is unknown. This study explores how feedback can be improved to increase acceptability and usability in primary care. The trial seeks to determine whether a theory-informed worksheet appended to feedback reports can help family physicians improve quality of care for their patients with diabetes and/or ischemic heart disease.


Two-arm cluster trial was conducted with participating primary care practices allocated using minimization to simple feedback or enhanced feedback group. The simple feedback group receives performance feedback reports every six months for two years regarding the proportion of their patients with diabetes and/or ischemic heart disease who are meeting quality targets. The enhanced feedback group receives these same reports as well as a theory-informed worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Participants are family physicians from across Ontario who use electronic medical records; data for rostered patients are used to produce the feedback reports and for analysis.


The primary disease outcomes are the blood pressure (BP), and low-density lipoprotein cholesterol (LDL) levels. The primary process measure is a composite score indicating the number of recommended activities (e.g., tests and prescriptions) conducted by the family physicians for their patients with diabetes and/or ischemic heart disease within the appropriate timeframe. Secondary outcomes are the proportion of patients whose results meet targets for glucose, LDL, and BP as well as the percent of patients receiving relevant prescriptions. A qualitative process evaluation using semi-structured interviews will explore perceived barriers to behaviour change in response to feedback reports and preferences with regard to feedback design.


Intention-to-treat approach will be used to analyze the trial. Analysis will be performed on patient-level variables using generalized estimating equation models to adjust for covariates and account for the clustered nature of the data. The trial is powered to show small, but clinically important differences of 7 mmHG in systolic BP and 0.32 mmol/L in LDL.

Trial Registration NCT00996645