Lo Vecchio, Andrea (2015) Evidence-based path in pediatric infectious diseases: from guidelines to quality improvement. [Tesi di dottorato]

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Abstract

Clinical practice guidelines (CPG) represent the standard of care in any medical field: in pediatrics CPG are aimed at providing appropriate health care and improving the health of infants and children by ensuring that they receive up-to-date, evidence-based care. As this thesis showed, the process that goes from the identification of a relevant clinical problem to its resolution is complex and time-consuming, and the delivery of standard care to the target population needs time and efforts. The production of a high quality guideline, based on a rigorous methodology, with the participation of relevant stakeholders and target users, is the first, essential step for a correct and effective evidence-based path. This thesis reported the development of the new European Guidelines for the management of acute gastroenteritis in children. However, for many health conditions, there is a gap between what medical science has shown to be effective in practice and what is actually done. In most cases the development of a CPG is not enough to change clinical practice. Further steps are always necessary and should include: pilot testing, capillary dissemination and implementation, local tailoring, and quality improvement. All these interventions need to be accurately planned, applied and monitored by expert personnel. This thesis reported the efficacy and effectiveness of different interventions in the field of pediatric infectious diseases that are the most common illnesses in infants and children. A routine and appropriate application of evidence-based recommendations may have a dramatic impact on the burden of all infections in pediatric age, improving child health and reducing inappropriate interventions, adverse effects and health-care expenses. In the field of acute intestinal infections, we observed a significant inappropriateness in current practice in Italy. The gap between standard of care and local practice may be resolved by using different approaches that improve practitioners' knowledge and significantly change their practice with consequential impact of child health. An e-learning course addressed to pediatricians and based on updated guidelines for the management of acute gastroenteritis has been tested with the collaboration of ESPGHAN and the United European Gastroenterology. We demonstrated a good applicability of this approach and its efficacy in changing clinical practice and adherence to guidelines in 11 European countries. In addition, we applied a quality improvement methodology to increase prescription of evidence-based interventions (probiotics) in children hospitalized for acute gastroenteritis in a tertiary-care hospital and we used a similar methodology to set up effective interventions to reduce infections' rate in children with acute leukemia, and demonstrated that moving central-line management from physicians and nurse to caregivers, by using a specific training, is one of the most effective interventions to reduce the rate of blood stream infections. Based on the data we obtained in this field, the message we can drive to health care authorities is to invest in translational medicine sciences and move part of health-care resources from production of evidence to their implementation.

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