Effect of Audit and Feedback on Adherence to Guidelines for the Management of Suspected Acute Uncomplicated Urinary Tract Infections by Medical Officers in Outpatient Settings- A Randomized Controlled Trial

Date of Award


Document Type


Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Professor Rodney Adam

Second Supervisor/Advisor

Professor Mary Adam

Third Supervisor/Advisor

Dr Gulnaz Mohamoud


Family Medicine (East Africa)


Background: Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Educational interventions have previously been used to improve the diagnosis and treatment of UTI with variable outcomes. Audit and feedback has been touted as a very effective method to change physician behavior and compliance to guideline driven practice. However, in developed countries its effect has been minimal, and there are no studies of its effect in Africa.

Objective: The study assessed the effectiveness of audit and feedback in influencing the adherence of guidelines for the management of acute uncomplicated urinary tract infections by medical officers.

Methods: This was a randomized controlled trial of 16 fulltime medical officers located at outpatient clinics in Nairobi affiliated with Aga Khan University Hospital. Each clinic provided one medical officer. From the 16 medical officers, eight were randomized to receive the Feedback and eight were assigned to the control group. All study participants received an Education program comprising: An interactive continuous medical education (CME) session with pre and posttest multiple choice questions (MCQs), two case vignettes that revolved around the guidelines, discussion on the sensitivity profile of the outpatient urine isolates, and electronic dissemination of the UTI treatment guidelines. Four months after the CME, doctors in the intervention group received feedback on the summary of their practice via a phone call. The primary analysis assessed overall guideline adherence in the feedback group versus the education only group. This was determined by comparing the median scores for guideline adherence for the two groups at the final audit using Kruskal-Wallis test and Mann-Whitney U test. We also analyzed the contribution of the five components that contributed to the overall adherence score. In addition, we assessed the trend line of the adherence scores at baseline, post-CME and post-feedback.

Results: Medical Officers’ adherence to UTI guidelines was audited during the three periods of pre-education (n=203), post-education (n=109) and post-feedback (n=66). The overall median score for the intervention group was 75 (IQR:67-80) and the control group was 80 (IQR: 75-85) (p-value=0.0084). Off all the five components, only physical examination showed a difference between the intervention and the control group (Median score 10 vs 7. pvalue =0.029.) There was for an in improvement from the pre-CME audit to the post-feedback audit for each of the control and the intervention arm for the overall scores. The intervention group also improved in the post-feedback period from the post- CME period.

Conclusions: The feedback intervention did not lead to improvement in guideline adherence in comparison to the CME. In contrast, the CME led to improved patient care in history taking, investigations and treatment components in the adapted guidelines.

This document is available in the relevant AKU library