Audit as a Tool for Improving the Quality of Stroke Care: A Review

Introduction: A clinical audit is a tool that allows the evaluation of and improvement in the quality of stroke care processes. Fast, high-quality care and preventive interventions can reduce the negative impact of stroke. Objective: This review was conducted on studies investigating the effectiveness of clinical audits to improve the quality of stroke rehabilitation and stroke prevention. Method: We reviewed clinical trials involving stroke patients. Our search was performed on PubMed databases, Web of Science, and Cochrane library databases. Of the 2543 initial studies, 10 studies met the inclusion criteria. Results: Studies showed that an audit brought an improvement in rehabilitation processes when it included a team of experts, an active training phase with facilitators, and short-term feedback. In contrast, studies looking at an audit in stroke prevention showed contradictory results. Conclusions: A clinical audit highlights any deviations from clinical best practices in order to identify the causes of inefficient procedures so that changes can be implemented to improve the care system. In the rehabilitation phase, the audit is effective for improving the quality of care processes.


Introduction
Stroke is one of the main causes of death and disability worldwide, causing 5 million deaths [1]. According to the World Health Organization (WHO), an instance of ictus occurs every 5 s [2]. Stroke is a clinical syndrome associated with rapidly developing signs of focal or global loss of cerebral functions, with a cause of vascular origin [3].
The acute phase is extremely important for a successful rehabilitation; in fact, there is a therapeutic window during which intervention is more likely to modify the course of the disease and successfully lead to neuronal reactivation [4,5]. Receiving organized hospital care in a stroke unit is associated with patients being more likely to be alive, independent, and living at home 1 year after their stroke compared to patients who do not receive such specialized care [6]. Preventive interventions are also essential to reduce the risk of recurrence. Prevention processes include encouraging a healthy lifestyle with regular physical activity and balanced nutrition to keep body weight and blood cholesterol levels under control, and with limits on alcohol, smoking and drug consumption [7].
For the treatment of stroke, therefore, phases of rehabilitation and preventive care are extremely important. For this reason, it is critical to find ways to evaluate and improve stroke care processes. An adequate tool to evaluate these elements is the audit.
The clinical audit is seen as one approach to improving the quality of patient care [8,9]. Specifically, a clinical audit is the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient. In other words, the audit is the process of reviewing the delivery of care to identify deficiencies so that they may be remedied [10,11].
The clinical audit can be described in four main phases: (i) planning (stating the aim, defining improvement, deciding quantifiable change); (ii) doing (collecting data, monitoring progress, providing feedback); (iii) studying (discussing data, assessing data, interpreting data); and (iv) acting (continued action) [12]. Clinical audits are largely used in medical care, both locally (local hospitals and medical centers) and nationwide (to improve the national health system). However, since audits are rarely published and available to the wider community, it is hard to both identify a common practice and evaluate their outcomes [13].
Indeed, no agreement exists about which audit methodologies are the most suitable approach, and, not surprisingly, there is significant confusion among healthcare professionals about how to implement an audit and integrate it effectively into clinical practice [10].
Given the high variability in audit methodologies, and the importance of improving clinical practice for stroke care, this review focused on the studies that investigated the efficiency of clinical audits to improve quality care for stroke (rehabilitation and prevention) by taking into account clinical trials carried out on patients with ictus.

Materials and Methods
A descriptive review was conducted on studies that performed a trial on the care process for rehabilitation and prevention of stroke that used the audit for assessment of quality care.
Studies were identified by searching PubMed (from 1972 to 2022), Web of Science (from 1991 to 2022), and the Cochrane library (from 1989 to 2022) databases, published before 7 October 2022. The keyword search was conducted by one researcher and took about 2 days.
The search keywords were "stroke" AND "audit" ("stroke" [MeSH Terms] OR "stroke" [All Fields]) AND ("audit" [MeSH Terms] OR "quality of care" [All Fields] OR "assessment of quality" [All Fields] OR "improvement of care" [All Fields] OR "improvement of quality" [All Fields] OR "revision process" [All Fields] OR "revision of care" [All Fields]). After duplicates had been removed, all articles were evaluated based on title, abstract, and text.
Studies that met the following criteria were included in this review: Evaluation of the studies was completed over three rounds (each study was tripledchecked for inclusion) by the same researcher who carried out the keyword search. This phase took about 1 month.

Results
Out of the initial 2543 studies identified from our search, 10 studies met the inclusion criteria ( Figure 1). All included studies examined the quality of stroke care using the audit as ment tool (see Table 1). Of 10 studies that evaluated the quality of stroke care, rehabilitation [14][15][16][17][18][19][20] and 3 regarded prevention [21][22][23]. For a detailed descrip ferent audit interventions see Table 2.  All included studies examined the quality of stroke care using the audit as an assessment tool (see Table 1). Of 10 studies that evaluated the quality of stroke care, 7 regarded rehabilitation [14][15][16][17][18][19][20] and 3 regarded prevention [21][22][23]. For a detailed description of different audit interventions see Table 2.    Step approach to the guidelines divided into 3 phases: phase 1 (training meetings), phase 2 (educational awareness visit), phase 3 (mail dissemination and reinforcement interventions).

Studies on Rehabilitation
Of the seven studies that evaluated the quality of rehabilitation in stroke patients, five audited both intervention and control groups [14,15,[18][19][20], while two studies audited the intervention group only [16,17].
Overall, results from studies that audited both groups show that an audit is an effective tool to improve the quality of rehabilitation in stroke patients. For example, Power et al., 2014 [14] reported a 10.9% improvement after implementing a Breakthrough Series (BTS) intervention, which includes a team of quality improvement experts, three training meetings, and an implementation phase. McGillivray et al., 2017 [18] and Hinchey et al., 2010 [19] found encouraging results for audit effectiveness, specifically when feedback was given within one day by a coordinating nurse (concurrent review) and when a multifaceted intervention was included. Consistent with these studies, Joliffe et al., 2020 [20] showed audit-related improvement specifically when therapists received the facilitator-mediated guideline package. Sulch et al., 2002 [15] carried out a study on 152 patients comparing whether the Integrated Care Pathway (ICP)-i.e., a multidisciplinary set of progressive care delivered within a specific time frame-improves the quality of care compared to routine care. Results showed that ICP, compared to routine care, was associated with greater improvement in initial assessments, better documentation of the diagnosis, and a higher rate of discharge within 24 h.
In contrast to the studies just presented that audited both groups, Linch et al., 2016 [16] and Machine-Carrion et al., 2019 [17] carried out an investigation of the effectiveness of the multifaceted intervention by auditing the intervention group only.
In particular, Lynch et al., 2016 [16] carried out a study in Australia involving a total of 586 patients over a period of 14 months. The objective was to compare two groups, one receiving education-only intervention and one receiving a multifaceted intervention, with the audit performed on the latter group only. The results showed that, similarly across the two groups, the odds for a patient to receive an assessment for rehabilitation were 3.69 times greater in the post-intervention period compared to the pre-intervention period, with no difference between the two interventions.
In the study by Machine-Carrion et al., 2019 [17], patients from hospitals that had received usual care (no intervention) were compared with patients in hospitals that had received the multifaceted intervention, on which the audit was performed. Patients in intervention hospitals were more likely to receive all acute therapies during hospitalization than those in control hospitals.

Studies on Prevention
Of the three studies evaluating stroke prevention, two audited both experimental groups (i.e., intervention and control) [21,23], while one audited the intervention group only [22]. Wright et al., 2007 [23] carried out a study of approximately 2800 patients in the UK, finding an improvement in patients' adherence to atrial fibrillation and TIA therapy, which was significantly greater in the intervention group-who attended 5 meetings to improve adherence within guidelines-compared to the control group.
With a similar sample, Williams et al., 2016 [22] compared 12 hospitals in the USA and 2164 patients to see if a training intervention plus indicator feedback was more effective for improving quality than indicator feedback alone. The training intervention plus indicator feedback was associated with improvement in venous thrombosis prophylaxis (DVT), but the effect was not sustained long-term.
With a much larger sample of 12,766 patients, Geary et al., 2019 [21] carried out a study in Sweden, with the aim of improving the diagnostics and use of preventive drugs for stroke. In diagnosing TIA, but not ischemic stroke, there was an improvement in the intervention group compared with the control group. Instead, regarding preventive drugs use, the audit and feedback intervention did not lead to any improvement in patients with ischemic stroke/TIA.

Discussion
Stroke can be life-threatening in the short term and can cause a reduction in quality of life and, consequently, physical, emotional, and behavioral disabilities [6,24]. Over the past two decades, A&F strategies have been used for all areas of health care, namely, preventive, acute, chronic, and palliative care, with the aim of improving the quality of performance, reducing errors, and increasing safety [25].
First, considering stroke rehabilitation, the studies included here showed that an audit was generally associated with improved care processes. Specifically, the audit of rehabilitation interventions brought further improvements when it included a team of experts [14,15,19], an active training phase with facilitators [14,18,20], and concurrent, short-term feedback [18].
These conclusions agree with what Welsh et al., 1993 [26] identified as key factors for audit success. These include an enabling organizational environment, strong leadership and direction of audit programs, strategy and planning in audit programs, resources and support for audit programs, monitoring and reporting of audit activity, commitment and participation, and high levels of audit activity which is seen by its participants as engaging and relevant, with respects to its nature and impact. More recent studies further suggest that audit success increases if the audit and feedback is provided by professionals who are admired by healthcare professionals [27,28]. Furthermore, it has been demonstrated that it is essential for audit success that personnel trust the data being investigated and consider the clinical topics being audited important [29,30]. A prerequisite for an optimal audit leading to change is that clinicians are committed to behavior change [31].
In contrast, an audit of stroke prevention interventions seems to report conflicting results, and studies are too few to reach satisfactory conclusions. In particular, of the three studies examined, while two reported audit-related improvements in stroke prevention care, these results are limited by small samples [22,23] and lack of assessment of long-term effects [22]. When a much larger sample was considered, there were no positive effects of the audit on the prevention of ischemic stroke [21].
It was possible that some of the main barriers to clinical audit identified by Robinson 1996 [32] may have been responsible for the null results found in our review in relation to prevention care, including a lack of resources, lack of expertise or advice in project design and analysis, relationships between groups and group members, lack of an overall plan for audit, and organizational impediments.
Additional factors of audit failure could be due to lack of clear and easy-to-understand feedback [33,34] and a lack of cooperation and motivation from the parts involved [35]. Springer et al., 2021 [35], in fact, highlighted that healthcare professionals working as a team during the audit and feedback process have improved stroke care. However, it remains unclear why these barriers would have affected the success of the clinical audit on prevention care specifically, while rehabilitation care was found to be improved overall, at least across the studies reviewed here. It may be that the clinical audit may be a tool for improving patient care differently depending on whether care applies to prevention or rehabilitation.
Furthermore, the studies reviewed found that audits were performed differently, possibly due to variability in healthcare workforce knowledge of clinical audits [36] and/or variability in access to funds [10], making a systematic comparison of the various protocols difficult (Table 2) [10,37].
This review included a small number of papers as only 10 studies met the inclusion criteria. This, combined with the significant variability in methodologies among the cited studies, which in turn led to significant variability in study results, including both quantitative and qualitative outcomes, did not allow objective comparisons to be made between investigations. This made it impossible to conduct a meta-analysis, making it difficult to reach satisfactory conclusions; further studies are needed to verify the effectiveness of audits as a tool to improve interventions for stroke prevention. Despite these limitations, the present review is, to the best of our knowledge, the first to provide a detailed picture of the clinical trials that have evaluated the usefulness of audits in improving the quality of care for stroke patients, allowing for a systematic evaluation of audit effectiveness and identification of weaknesses, in turn enabling improvement so that more efficient future studies can be designed.

Conclusions
In conclusion, in light of the reviewed studies, the audit appears to be effective in improving the quality of care for stroke patients in the rehabilitation phase. More studies are needed to reach robust conclusions with regard to the preventive phase. Future studies should focus on applying standardized audit protocols to advance improvements in stroke care and allow for systematic comparisons between studies [38]. In order to improve clinical practice, a number of references may provide appropriate learning sessions and educational material regarding the following: the theory and practice of improvement [14,17,22]; meetings to improve adherence to guidelines [23,39]; case reviews conducted by researchers trained in the National Stroke Audit methodology [15]; regular conferences on quality measures and discussions of aspects that need to be improved [17]; and systems capable of quickly and regularly giving feedback [18]. Institutional Review Board Statement: Consent from the ethics committee was not required for the research.

Informed Consent Statement: Not applicable.
Data Availability Statement: Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Conflicts of Interest:
The authors declare no conflict of interest.