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Effects of audit and feedback on the quality of care and comfort in dying with dementia (FOLlow-up).

Boogaard, J.A., Steen, J.T. van der, Soest-Poortvliet, M. van, Anema, J.A., Francke, A.L., Achterberg, W.P., Vet, H.C.W. de. Effects of audit and feedback on the quality of care and comfort in dying with dementia (FOLlow-up). European Journal of Palliative Care: 2017 153. Abstract. In: Abstractbook 15th World congress of the European association for Palliative care: Progressing Palliative Care. 18-20 mei 2017, Madrid.
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Background
Despite increased attention for palliative care in patients with dementia dying in ursing homes, recent studies found burdensome symptoms and unmet family caregivers’ needs in the last phase of life. Audit- and feedback were expected to improve quality of palliative care.

Aim
To assess the effect of two audit- and feedback strategies on care quality in Dutch nursing homes using the EOLD-Satisfaction With Care scale (EOLD-SWC) and on outcome using the EOLD-Comfort Assessment in Dying scale (EOLD-CAD).

Methods
In a cluster randomized controlled trial, two auditand feedback strategies, either generic feedback based on mean EOLD-scores or feedback with patient-specific EOLDscores (six nursing homes each) were compared to a control group (six nursing homes) without feedback. The intervention groups discussed EOLD-ratings representing family views after
death-in team meetings and formulated actions for care improvement. Multi-level analyses were performed to assess effects and a process evaluation catalogued barriers and facilitators of the intervention using semi-structured interviews.

Results
A total of 668 families rated the EOLD-instruments. Compared to no feedback, the generic strategy resulted in lower satisfaction in both adjusted and unadjusted analyses, while the patient-specific strategy increased comfort in unadjusted analyses only. The interviews showed that staff felt that regular team discussions about EOLD-scores were
not always feasible. Improvement actions were not formulated sufficiently clear enough and were not followed-up, and favorable EOLD-scores did not seem to motivate teams to do better.

Conclusion
The disappointing effectiveness of audit and feedback may be explained by suboptimal conditions and insufficient skills to translate the feedback into care improvements. Feedback with favorable family ratings might even have triggered opposite effects in the context of Dutch long-term care. Trial number: NTR 3942.