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01.12.2017 | Research article | Ausgabe 1/2017 Open Access

BMC Family Practice 1/2017

Effect of audit and feedback with peer review on general practitioners’ prescribing and test ordering performance: a cluster-randomized controlled trial

BMC Family Practice > Ausgabe 1/2017
J. Trietsch, B. van Steenkiste, R. Grol, B. Winkens, H. Ulenkate, J. Metsemakers, T. van der Weijden
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12875-017-0605-5) contains supplementary material, which is available to authorized users.



Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting.


We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis.


Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements.


Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands.

Trial Registration

This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007.
Additional file 1: Appendix 1. Complete set of texts sent to GPs together with the feedback. Texts are pasted here in one document. (DOC 1843 kb)
Additional file 2: Appendix 2. Complete set of drugs and tests included in the databases for this intervention. (DOCX 33 kb)
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