Trends in behaviour change techniques for implementing and de-implementing healthcare practices using audit and feedback

Abstract

Abstract Background Audit and feedback (A&F) is a widely used quality improvement strategy in which a summary of healthcare professionals’ (HCPs) practice is provided to support behaviour change. However, its application and effectiveness within randomized controlled trials (RCTs) of practice-change interventions vary considerably. Examining variation in the behaviour change techniques (BCTs) used within A&F interventions and the contexts in which they are applied may help optimise their design and delivery. Therefore, this study explored associations between the BCTs used in A&F interventions, the direction of behaviour change (implementation versus de-implementation), and target behaviour type. Methods An exploratory secondary analysis was conducted using data from 261 RCTs of A&F interventions, originally extracted as part of a Cochrane systematic review. Binary logistic regression models investigated whether different BCTs were more frequent in interventions for the implementation versus de-implementation of HCP practice. These analyses were repeated in subgroups of different behaviour types (e.g. prescribing, testing/examinations). Results Descriptive analyses of 261 RCTs (942 target behaviours) indicated that BCTs were used with broadly similar frequency for implementation (n = 732 behaviours) and de-implementation (n = 179 behaviours). Due to substantial clustering within studies, regression model estimates were unstable and not interpreted inferentially. Across the full sample, most BCTs showed minimal differences in use between implementation and de-implementation. Subgroup analyses by behaviour type suggested some variation, with certain BCTs (e.g. feedback on outcomes of behaviour) appearing to be used differentially depending on the type of practice being modified. However, overall patterns were largely consistent across behaviour categories. Conclusions These findings suggest that A&F interventions typically use similar BCTs regardless of whether they aim to increase or decrease HCP behaviours, and largely irrespective of behaviour type. This may indicate that current A&F intervention design does not systematically account for the direction or nature of behaviour change. While some variation was observed by behaviour type, the absence of clear differentiation highlights a potential mismatch between theoretical expectations and practice. Future research should use theory-informed designs to determine whether tailoring BCTs to behaviour change direction or type improves A&F intervention effectiveness.