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More than 30% of studies focused on multiple interventions. This meant that the effects of the interventions or intervention components could not be independently identified. This was particularly true in QI studies set in hospitals and physician practice settings.

Information technology and consumer engagement in healthcare are current hot topics in QI studies. Yet similar to nursing home studies, much of the literature in these areas focuses on describing the development or implementation of information technology or consumer engagement, with researchers paying less attention to evaluating of how these changes relate to QI.

Physicians argue that quality-of-care outcomes based on administrative databases don't provide subtle enough data to be of value. However, research gleaned from individual patient charts is expensive. Researchers evaluating QI effectiveness have to weigh up these considerations. It is also easy to mistakenly draw conclusions about how effective a particular QI intervention is by comparing studies that draw upon different sample types. Only QI studies in nursing homes, physician practices, and other health delivery organizations tend to be large enough to statistically test how effective QI changes are across certain organizational conditions. Most hospital QI studies are too small.

In terms of study design, the majority (62%) of studies employed observational techniques, and 38% used experimental/randomised control trial (RCT) designs. RCT studies are the gold standard in research, to establish internal validity and causality, but these are not always appropriate in practice: For example, it may be difficult to randomise patients or providers to experimental and control groups when necessary treatment may be withheld.

Many QI studies were opportunistic, in other words unfunded studies of a
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