Changing Outcomes Through Achievement Emails in COPD Using Routine Healthcare Audits

Audit and feedback (A&F) is defined by Ivers et al. as the "provi(sion of) a recipient with a summary of their performance over a specified period of time" and has long history of use within a diverse area of research and business to promote clinician and organisational behaviour change. In healthcare, A&F has been used either alone, or as part of a composite quality improvement project (QIP), to improve health practitioner practice based on guidelines or targets. A 2012 Cochrane review systematically reviewed 140 papers on A&F spanning several decades and produced a meta-analysis showing an absolute risk difference (RD) in practitioners changing behaviour to comply with the preferred practice of 4.3% (interquartile range 0.5% to 16%). Their investigation emphasised that A&F is particularly effective when it is targeted specifically at prescribing practices (mean adj. RD 13.1% verses diabetes management 0.5%) and where baseline compliance is low.

Meta-regression of the Cochrane data showed that the effect size of A&F has remained largely unchanged over the last two decades of study, leading the authors to postulate that there is no longer reasonable clinical equipoise to question if A&F is effective. However, they also conclude that studies aiming to isolate how A&F can be utilised most effectively by comparing different A&F variations are few and far between and that this should be the target of future A&F research.

A&F has previously been used successfully within the West Yorkshire Clinical Commissioning Group (CCG) - now replaced by the NHS West Yorkshire Integrated Care Board (ICB) - to effect change on primary care prescribing practices. The ASPIRE cluster Randomised Controlled Trial (cRCT) of A&F in this region produced a reduction in risky prescribing (odds ratio 0.82), while the CROP quasi-experimental controlled interrupted time series analysis of A&F correlated with 15,000 fewer patients being inappropriately prescribed opioids over a period of a year compared to controls (35,36). Both studies utilised a similar A&F design, utilising a theoretical structure based around the Theoretical Domains Framework (TDF) that is ideal for determining the possible perceptions of interventions by its intended targets. They also operated the Behaviour Change Taxonomy (BCT) to describe their employed behavioural change techniques and their intended effects.

The combined Long-Acting Beta Agonist / Inhaled CorticoSteroid (LABA+ICS) inhaler category has been used to treat COPD patients who present with asthmatic features of partially reversible lung function in the past. The most recent Global Initiative for Chronic Obstructive Lung disease (GOLD) guidelines move away from this however, by actively suggesting their use should be discouraged in favour of LABA-Long-Acting-Muscarinic-Antagonist-ICS (LABA-LAMA-ICS) triple inhalers. This is based on two separated studies suggesting LABA-LAMA-ICS inhalers reduced exacerbations of COPD in a subset of patients compared to LABA-ICS. In 2018, an observational study in the UK suggested that LABA/ICS usage in the COPD population was approximately 20%.

Precision feedback is a concept that suggests that aligning feedback messaging to individual, objective performance and goals may improve the performance of audit and feedback to create change. Here we propose to use the opportunity provided by a pre-planned QIP into COPD prescribing in West Yorkshire to undertake a randomised controlled trial to address this question.