Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

Background Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study. Methods We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour. Results Data saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years' experience. When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages' motives and consider gaming. Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient. Conclusion Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.

Automated summary

The practice of colonoscopy audit and feedback may have unintended negative consequences, such as reducing confidence in healthcare providers, increasing anxiety, and causing patient discomfort. To minimize these harms, it is important to clarify the motivation behind feedback, develop targeted improvement plans, and provide support for confidence.