For many important child health conditions, the quality of care in Australia may not be optimal, according to a study recently published in the Journal of the American Medical Association (JAMA).
The chief investigator, Professor Jeffrey Braithwaite, founding director of the Australian Institute of Health Innovation at Macquarie University, explores in the article below some of the study’s implications for healthcare practice and policy.
Ensuring children receive care in line with clinical practice guidelines is very likely to lead to better health and more effective use of limited healthcare resources, he says.
Jeffrey Braithwaite writes:
Does it matter that Australian children receive healthcare in line with clinical practice guideline recommendations 60 percent of the time?
Results from the CareTrack Kids study, published in JAMA last week, provoke this question.
The study, the largest of its kind, was led by the Australian Institute of Health Innovation, Macquarie University with partners from University of New South Wales, Sydney Children’s Hospitals Network, National Health and Medical Research Council, BUPA Health Foundation, New South Wales Health, the Clinical Excellence Commission, University of South Australia, Children’s Health Queensland, South Australian Department of Health and the Australian Commission on Safety and Quality in Healthcare.
CareTrack Kids evaluated care for 6,689 children under 16 years of age using 160,202 clinical indicator assessments, looking at how often care was given in line with clinical practice guideline recommendations for 17 common childhood conditions.
Medical records were surveyed in four clinical settings (general practices; paediatricians’ offices; hospital emergency departments; and hospital inpatient wards) in New South Wales, South Australia and Queensland.
There was substantial variation in adherence to guidelines by clinical condition: by way of example, there was 89 percent adherence on average for the management of autism, 58 percent in the management of asthma, 54 percent in the management of fever, and 44 percent for tonsillitis.
While seeking to improve health outcomes for patients, substantial investments have been made in developing clinical practice guidelines, to support the delivery of evidence-based healthcare.
For CareTrack Kids, experts in each clinical condition identified key clinical indicators from the relevant clinical practice guidelines that could reasonably be expected to apply to the care of a child in Australia for the period of the study, 2012-2013.
Australia’s health system is one of the best in the world, with highly trained medical professionals who can make informed decisions for each child who comes to them for care. While recommendations are just that, recommendations, there are many benefits to the community and health system as a whole for adherence to good quality clinical practice guidelines.
Prior to CareTrack Kids, little was known about the level of adherence to the recommendations arising from these guidelines for the care of Australian children.
With the results from CareTrack Kids now published, we have to reflect on the fact that children being treated for autism receive care in line with clinical practice guidelines almost 90 percent of the time.
For example, one of the clinical indicators assessed revealed that children are being appropriately referred to occupational therapists and speech pathologists to receive individualised service aimed at building the child’s skill and ability to participate in everyday activities.
The study also looked at several clinical indicators for asthma, including how often a child prescribed a preventative asthma inhaler was given a written asthma action plan. The use of a written asthma action plan improves a child’s health, reduces time off school and ultimately alleviates the burden on the health system that spends millions of dollars on asthma care.
The report shows that children who are prescribed a preventative asthma inhaler in some settings are almost always provided a written asthma action plan but not in others. This becomes particularly troubling when a child suffers an acute episode and immediate specific actions need to be taken – it should not be left to the memory of the child or carer, as a written plan can save lives.
Adherence with clinical practice guidelines could also improve in the case of children with gastro-oesophageal reflux disease. Children under one year of age with reflux who are otherwise healthy and thriving are being treated with acid suppression medication at the first presentation in 41 percent of cases.
Clinical practice guidelines do not recommend this and, in fact, the evidence of effectiveness of acid suppression medication in infants is not strong and is associated with increased infections.
So, does the rate of adherence to clinical practice guideline recommendations matter? What are the implications for policy and practice? Does non-adherence result in reduced health outcomes for children?
Without application of evidence-based care, can an already stretched health system cope? Can health system performance be properly gauged without monitoring quality metrics derived from clinical practice guidelines?
These are all critical questions and point to why this significant research is highly overdue.
By studying the level of adherence to clinical practice guideline recommendations, a benchmark can be established for improvements to build on.
From here, avenues can be explored to help clinicians deliver the right care at the right time to the right person. This will result in better health outcomes for the community and a more efficient and effective health system.
Going forward, the Australian health system must consider the full picture of clinicians’ decision-making processes and the systems that support them.
Clinical practice guidelines are not perfect, but they are a distillation of what is known about the best way to care for specific conditions.
Often, they are based on clinical trials, sometimes on consensus. Either way CareTrack Kids provides a valuable freeze frame of how the system is performing. This is not a report card on individual clinicians, rather a reflection of the system they work within.
The evidence is now available to look at each clinical condition and identify the practices that are most likely to benefit from interventions to improve adherence. Intervention targets can then be prioritised, based on the likely costs and anticipated benefits of intervening.
Clinical indicators need to be standardised nationally and kept current, as has been done for asthma with the Australian Asthma Handbook. The ongoing roll out of electronic health records creates the opportunity to implement a monitoring and feedback system with clinicians to create a positive quality improvement cycle.
It matters that children in Australia receive care in line with guidelines. When this happens, health outcomes are very likely to improve, and limited healthcare resources get targeted most effectively.
While a figure of 60 percent adherence is better than the rate published by a similar American-based study over a decade ago, Australia has room for improvement and would stand to gain a lot.
• Professor Jeffrey Braithwaite, PhD, founding director of the Australian Institute of Health Innovation at Macquarie University and Chief Investigator of the CareTrack Kids Study in the Journal of the American Medical Association: Quality of Health Care for Children in Australia, 2012-2013.
• Follow on Twitter: @JBraithwaite1
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