Implementation of the WHO standards to assess the quality of care for children with acute diarrhoea: findings of a multicentre study (CHOICE) in Italy

Background: There is no documented experience in the use of the WHO standards for improving the quality of care (QOC) for children at the facility level. We describe the use of 10 prioritised WHO-Standard-based Quality Measures to assess QOC for children with acute diarrhoea (AD) in Italy. Methods: In a multicentre observational study in 11 paediatric emergency departments with different characteristics and geographical location, we collected data on 3061 children aged 6 months to 15 years with AD and no complications. Univariate and multivariate analyses were conducted. Results: Study findings highlighted both good practices and gaps in QoC, with major differences in QOC across facilities. Documentation of body weight and temperature varied from 7.7% to 98.5% and from 50% to 97.7%, respectively (p<0.001); antibiotic and probiotic prescription rates ranged from 0% to 10.1% and from 0% to 80.8%, respectively (p<0.001); hospitalisations rates ranged between 8.5% and 62.8% (p<0.001); written indications for reassessment were provided in 10.4%-90.2% of cases (p<0.001). When corrected for children's individual characteristics, the variable more consistently associated with each analysed outcome was the individual facility. Higher rates of antibiotics prescription (+7.6%, p=0.04) and hospitalisation (+52.9%, p<0.001) were observed for facilities in Southern Italy, compared with university centres (-36%, p<0.001), independently from children characteristics. Children's clinical characteristics in each centre were not associated with either hospitalisation or antibiotic prescription rates. Conclusions: The 10 prioritised WHO-Standard-based Quality Measures allow a rapid assessment of QOC in children with AD. Action is needed to identify and implement sustainable and effective interventions to ensure high QOC for all children.