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How to publish audit

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.334.7585.sgp26 (Published 20 January 2007) Cite this as: BMJ 2007;334:gp26
  1. Ricky Banarsee, director of West London Research Network

Abstract

Audit maestros Dennis Ougrin and Ricky Banarsee help you make a lasting impact

All doctors in training are required to complete audit projects. This is often perceived as a mundane and pointless exercise. We explore how audits could be published.

What has been published?

An 18 month review of EMBASE and MEDLINE reveals about 1200 and 850 articles on medical audit respectively. However, only a fraction are published in core clinical journals. In MEDLINE this amounts to about 90 articles broadly related to audit or 25 articles specifically describing audit.

Some published audits are not audits at all. Confusion happens around surveys. Hassan and colleagues describe an audit of laboratory mycology services for the management of patients with fungal infections.1 This appears to be a broad survey of laboratory practice and training needs but does not seem to compare these with any standards. In fact the authors state that despite there being proposed standards of practice recommended by the British Society for Medical Mycology their “primary reasons for this audit did not include measuring practices against these standards.”

What themes do published audits consider?

Improving outcomes

These are outcome audits, as opposed to process or structure audits. Wilson and colleagues2 measured haemoglobin A1c levels, mean diastolic blood pressure, and cholesterol levels after introduction of a new healthcare delivery system, showing improvement in these intermediary measures in a large population sample. Another example, by Young and colleagues, showed how introduction of a learning collaborative could improve outcomes in paediatric care.3

Think of the journal most likely to publish. Generally, local audits should be published locally, national ones in national journals

Improving structures

These have a completed audit cycle with significant and important results showing that structural changes improve outcomes. Bampton and colleagues targeted appropriate time intervals between follow-up endoscopies and the proportion of patients who had appropriate numbers of biopsies collected at endoscopy.4 This was identified as an issue by a retrospective audit and the change was attempted by (a) disseminating guidelines, which made no difference, and (b) introducing surveillance coordinators, which made a sizeable difference.

Improving process

These are audits with a completed cycle improving practice significantly. Woolley and colleagues report that introduction of a clinical scoring system reduced the inappropriate prescribing of antibiotics from 44% to 11%.5 Correct antibiotic prescription rose from 60% to 100%.

Generating benchmarks

These are usually large audits that generated vast data sets. Analysis leads to clinically important findings and may serve as benchmarks for quality ratings. Nguyen and colleagues audited outcomes of over 1000 surgical procedures at leading US hospitals, generating benchmark complication and mortality rates but also confirming differences in outcomes.6

WHAT THEMES DO PUBLISHED AUDITS CONSIDER?

  • Improving outcomes

  • Improving structures

  • Improving process

  • Generating benchmarks

  • Showing clinically important correlations

Showing clinically important correlations

These are also large audits that generated vast data sets. Analysis leads to clinically important associations. Friedman and Ebrahim audited adequacy of blood transfusion documentation and correlated this with justification for the transfusions, revealing, unsurprisingly, a strong correlation.7

Most leading clinical journals publish only completed audit cycles

I have an incomplete audit cycle. Does this mean I can't publish it? No, as the following two examples show.

Uncovering important data

Barber and colleagues published audit data confirming high quality documentation of donor recruitment in intensive care and that most clinicians keep to the guidelines.8 The results showed the main obstacle was the family withholding consent and a higher rate of withholding consent in some ethnic minorities.

Uncovering need for changing practice

Habel and colleagues identified a high proportion of cases of cleft palate were identified late, and proposed to improve junior paediatricians' training.9

What are the characteristics of a publishable audit?

Auditing outcomes, not processes or structures

Doctors need to decide between auditing processes, outcomes, or structures.10 Junior doctors are most likely to audit clinical processes because outcomes may take a long time to develop and structures (such as service configuration or numbers of staff employed) are rarely changed by juniors. Gold standards usually regulate processes—for example, what we need to prescribe or who needs to be involved. The audit is more likely to be published if it deals with outcomes.23

Auditing the right topic

Your trust will be aware of national audits and your research and development department should be able to advise. Make sure you compare current practice with the broadly acceptable guidelines or standards available, such as those published by the National Institute for Health and Clinical Excellence (www.nice.org.uk).

Large prospective sample

This has a direct bearing on generalisability and applicability of your results. Can you link your audit with other audit projects tackling the same problem? Can you find other people interested in the issue? Can you use electronic patient records databases? It is also better to gather data prospectively to avoid biases in retrospective samples.

Linked to research or service innovations

Research is concerned with generating new knowledge while audit seeks to ensure knowledge is translated into practice. Audit is about quality and research is about knowledge. Audit often generates research questions and research can be complemented by audit.

Not only generalisable, important, and applicable results but also statistically significant

Statistical analysis is a must. This does not have to be too sophisticated but needs to show statistically significant deviation from standard practice.

Have a completed audit cycle

Although it is possible to publish audits with an incomplete audit cycle those are the exceptions. Have enough time to complete the audit cycle. If that is impossible try to find someone who will complete your cycle, or look for an incomplete audit you might like to finish.

Improving structures have a completed audit cycle with significant and important results showing that structural changes improve outcomes

Are submitted to the right journals in the right way

Think of the journal most likely to publish. Generally, local audits should be published locally, national ones in national journals, and audits of universal interest in international ones.

Write your audit report in the journal article format. It is worth reading author guidance and keeping to house style. Can you find a similar article in the journal? If not, you have chosen the wrong journal. Check with your local research ethics committee if your audit requires ethical approval.

I still can't publish my audit

Post it as a rapid response to a relevant article. You will almost certainly get a web publication and your rapid response may be published as a letter.

And finally...

Writing any audit provides an opportunity for publication. It is important to bear this in mind from the first day of your audit project to increase your chances of success.

USEFUL LINKS

  • www.iatam.org: lists of organisations that offer breakaway training

  • www.cfsms.nhs.uk: replaced the zero tolerance website and has a legal team

  • Not alone—guide for the better protection of lone workers in the NHS. Excellent safety tips. Access through the cfsms website

References

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