IMPLEMENTATION SCIENCE IN THE TIME- DEPENDENT DISEASE. THE RELEVANCE OF AN AUDIT AND FEEDBACK AT NETWORK LEVEL

There is extensive evidence from every country that there is a gap between the health care that patients receive and the practice that is recommended. Specifically, in Italy there is clear evidence of wide variability among facilities in the health processes and outcomes of the health services offered. Audit & Feedback (A&F) interventions are an effective way to promote professional behavior changes and improve the quality of care. Recommendations on how an A&F system should be conceived and developed to be able to fully exploit its potential have been provided by experts in the field. However, the actual applicability of these recommendations - based on the available evidence and on assumptions from theories of behavior change and common sense - should not be taken for granted. A&F are indeed complex interventions strongly influenced by the context, whose implementation poses several challenges in terms of competences and skills for its conceptualization and design, and technical problems for its application. In Italy, A&F strategies are less applied and studied than in other countries, such as United Kingdom and Canada. This PhD thesis tests the feasibility of audit A&F strategies in the real-life emergency care setting in Italy. In time-dependent conditions, early recognition of symptoms as well as timely and appropriate interventions are key elements in improving disease management. The design and implementation of specific A&F interventions targeted at the different facilities involved in the emergency network can be effective in achieving this goal. The three papers reported, developed, and published during the PhD program, aim to answer to the following research questions: how to design and implement A&F intervention in Emergency Care (articles 1 and 2); how to test the effectiveness of an A&F intervention in emergency care setting (article 3). Articles one and two describe the designing and implementation of A&F in Emergency Care in the framework of the national research program EASY-NET: Effectiveness of Audit & Feedback strategies Network, launched in 2019 by the Italian Ministry of Health with participating Institutions in seven regions (Lazio, Friuli-Venezia Giulia, Piedmont, Emilia-Romagna, Lombardy, Calabria, and Sicily). Highlighting the baseline lacks or differences in A&F strategies in the Lazio region Emergency Network, we developed an effective strategy to improve outcomes in the Emergency Care pathways. To perform this improvement, in the first article a survey has been developed and administered to health care professionals in all the hospitals participating in the Network. Then, an intervention has been designed and tested. The second article, involving experts (healthcare managers and clinicians) from Cerebrovascular and Cardiovascular Lazio Region Emergency network, describes the methodologies and the preliminary results of the intervention proposed. A two-round Delphi survey was conducted, preceded by a preliminary phase in which new indicators were developed and discussed by the experts. The way for feedback reporting was defined through a web-based survey, administered to clinicians and hospital managers, aimed to compare different alternatives of graphical representation of data for feedback, making both an objective and subjective assessment of the clarity, completeness, and comprehensibility of the proposed alternatives. Finally, the third article reports a quantitative evaluation of effectiveness of the new structured A&F intervention with that of the "standard strategy" in improving the adequacy and timeliness of emergency health interventions in patients with Acute Miocardical Infraction (AMI) and Stroke in the Lazio Region, measured with appropriate process and outcome indicators. A prospective quasi-experimental pre–post study with a control group was conducted. The current performance measurement systems in Italy provide feedback on time-dependent care conditions, but do not allow the evaluation of network level interventions. This thesis is an implementation research, evaluating an A&F intervention involving all actors of the time-dependent emergency network, in the context of the Lazio region. In an era of increasing complexity and demand for value, the insights generated aim to enhance Evidence-based practice and contribute to the ongoing evolution of healthcare delivery models.The results obtained in this three-year experience provide new scientific evidence on quality of care and research applied to real-life clinical practice. The methodology employed in the published articles is replicable and applicable in other healthcare settings. The provision of feedback and the establishment of cyclical audit processes could support the effective implementation of networks that improve the appropriateness and timeliness of emergency health interventions for patients with time-dependent conditions.