EXPERT REACTION: Australian kids' healthcare may be 'inadequate'

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An assessment of the quality of routine healthcare for children in Australia in 2012 to 2013 has found we may be falling short in some areas when it comes to looking after our sick kids. Australian researchers looked at a total of 6,400 medical records for 17 different conditions, covering 6,689 children aged 15 or under, and representing 15,240 medical encounters across three states - NSW, QLD and SA. In total, this generated 160,202 quality indicator assessments. They found children did not receive treatment in line with guidelines in 39.5 per cent of cases of non-communicable diseases, such as asthma and diabetes, in 17.6 per cent of mental health cases, in 43.7 per cent of acute infection cases, and in 21.7 per cent of head injuries. Overall, treatment was not provided in line with guidelines in an average of 40.2 per cent of cases. The authors describe Australian healthcare for kids as "inadequate".

Journal/conference: JAMA

DOI: 10.1001/jama.2018.0162

Organisation/s: Macquarie University, University of South Australia, The University of New South Wales, The University of Sydney

Funder: The research was funded as an Australian National Health and Medical Research partnership grant (APP1065898), with contributions by the National Health and Medical Research Council, Bupa Health Foundation, Sydney Children’s Hospital Network, New South Wales Kids and Families, Children’s Health Queensland, and the South Australian Department of Health (SA Health).

Media Release

From: Macquarie University

Australian children receive healthcare in line with guidelines 60 per cent of the time: National study

Landmark national CareTrack Kids study assessed the quality of healthcare delivered to children across 17 common clinical conditions

* Australian-first national benchmarking study shows children receive care within guidelines on average 60 per cent of the time

* Children with tonsillitis, gastroesophageal reflux disease and upper respiratory tract infections received care least in line with guidelines

* Mental health conditions, diabetes and head injuries received care most in line with guidelines

A landmark national study led by the Australian Institute of Health Innovation at Macquarie University on the standard of healthcare for children in Australia has found children receive care within with clinical practice guideline recommendations on average 60 percent (59.8 per cent) of the time for 17 common medical conditions.

The CareTrack Kids study published today in the Journal of the American Medical Association evaluated care for 6689 children under 16 years of age using 160,202 clinical indicator assessments, looking at how often care was given in accordance with clinical practice guideline recommendations.

There was substantial variation in adherence to guidelines by clinical condition: for example, there was almost 89 per cent adherence on average for the management of autism, 58 per cent in the management of asthma, 54 per cent in the management of fever, and 44 per cent for tonsillitis.

In practice, this could mean that rather than complying with guidelines for tonsillitis, fever or upper respiratory tract infection, a clinician may treat a child with antibiotics instead, contrary to recommendations. Reduction in the unwarranted use of antibiotics is strongly supported by public health authorities.

Six conditions had estimated adherence to guidelines greater than 70 per cent – four mental health conditions, diabetes and head injury.

Conditions treated most in line with clinical practice guidelines
Head injury
Abdominal pain

Conditions treated least in line with clinical practice guidelines
Gastroesophageal reflux disease
Upper respiratory tract infection
Otitis media (middle ear infections)
Acute gastroenteritis

“The rate of high-quality care for Australian children across these very common conditions varies considerably,” said Professor Jeffrey Braithwaite, lead author of CareTrack Kids and Founding Director of the Australian Institute of Health Innovation at Macquarie University.

“With the release of these results, we need to reflect on how we can improve the healthcare system. Clinicians want to do their best for all their patients and we need to modify the system to help them achieve this goal.

“We also recognise that guidelines should not be followed slavishly all the time. There are always exceptions, including that a family’s preferences matter or that there are clinically relevant reasons for deviations.

“We suggest several improvements to the health system, including advancing the design of electronic medical records, to give clinicians ready access to real-time information. We also need to collect patient data in a structured way when the child is being treated in order to support the clinician’s decision making and provide better information to their carers.

“There are always challenges. These results are as good as elsewhere in the world, but Australia can do even better.“This study highlights which conditions need most attention and will drive concerted efforts to improve patient care,” concluded Professor Braithwaite.

The study, the largest of its kind ever conducted, involved 139 healthcare provider sites: 85 GP clinics, 20 specialist practices and 34 hospitals across New South Wales, Queensland and South Australia. The study examined care provided to children in 2012 and 2013.

The original CareTrack adults study, published in 2012, found Australian adults receive appropriate healthcare in 57 per cent of consultations.


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Expert Reaction

These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.

Professor Jeffrey Braithwaite is founding Director of the Australian Institute of Health Innovation at Macquarie University and Chief Investigator of the just-published CareTrack Kids Study, the largest study of the quality of care to children ever undertaken

CareTrack Kids, a landmark national study on the standard of healthcare for children in Australia, found that children receive care in line with clinical practice guideline recommendations on average 60 percent of the time for 17 common medical conditions.

Australia has a world-standard healthcare system, but we could improve. Our results mirror studies in Australia and the USA suggesting that we need to increase provision of care in line with guidelines.

The CareTrack Kids study was designed with the assistance of experts in each clinical condition who identified key clinical indicators that would reasonably be expected to apply to the care of children in Australia in 2012 and 2013.  The study assessed the level of adherence to those clinical indicators as recorded by clinicians in the medical records of 15,240 medical encounters.

Every study has limitations and those for CareTrack Kids are outlined in the paper. One limitation is that it is possible clinicians could be adhering to guidelines different to those selected for the formulation of the clinical indicators, or they may not be recording their care fully in the medical records. This would not be picked up by the study.

We suggest several system improvements including re-designing and funding electronic health records to help clinicians provide care in line with guidelines, and to monitor and report adherence rates of clinicians in real time.

Clinicians want to do the best for all patients and we need to enhance the system to help them achieve this goal.

Last updated: 20 Mar 2018 12:56pm
Associate Professor Alexandra Martiniuk is an NHMRC TRIP Fellow at the University of Sydney and an Honorary Senior Research Fellow at the George Institute for Global Health

Quality of healthcare is an important consideration in Australia and globally.
Braithwaite and colleagues examined the quality of healthcare provided to nearly 7,000 children in 2012 and 2013 at 139 healthcare sites: 85 GP sites, 20 pediatricians’ offices, and 34 hospitals across three states in Australia (including urban and rural areas). 

While quality of care is the focus of this paper, it highlights underlying important issues regarding what exactly high quality care is. Ultimately, this brings us to think about challenges related to clinical practice guidelines - most of which are already well known, e.g. multiple guidelines for one condition. In fact, this study reviewed six guidelines per condition in preparation for its healthcare quality assessments.

Consolidated, governed and updated guidelines per condition are needed – and importantly – the strength of the evidence underlying the guidelines needs to be provided. Future research on healthcare quality could indicate the strength of the evidence upon which the recommendations are based, and then assess quality of care using only those recommendations with strong evidence.

We can use knowledge translation techniques to increase use of clinical practice guidelines and thereby potentially increase quality of care. But first, we need to ensure strong evidence underpins the guideline,  there are consolidated and easily available guidelines per condition, and the mechanism(s) of action recommended in the guideline are clear. This may assist with implementation. Yet the best evidence on asthma action plans (cited by Braithwaite, as well as a Cochrane review) indicates the mechanism of action of these plans is not known and that “there are limited data to firmly conclude that provision of an action plan is superior to none”. For instance, in this Braithwaite study, the use of asthma action plans was rare except for a child who was being discharged from a tertiary care hospital due to asthma. Better understanding the variability of guideline use may assist in ultimately improving quality of healthcare. 

Three key limitations of this research by Braithwaite et al are: (1) low health professional response rates of 25 per cent, potentially meaning the records reviewed were of better quality than others in Australia, (2) psychiatrist and clinical psychologist offices were not specifically examined although mental health care was an area of interest, and this may have underestimated the quality of mental health care in this study; (3) care documented may not be the care recorded and this may underestimate the quality of care actually provided.

Last updated: 19 Mar 2018 4:12pm

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