What percentage of children receive healthcare in line with clinical practice guideline recommendations?

Author: Peter Hibbert
Program Manager
Australian Institute of Health Innovation (AIHI)
Macquarie University

What percentage of children receive healthcare in line with clinical practice guideline recommendations?

As a society, we do not know the answer to this question. However, with ever-increasing possibilities and rising costs, healthcare is facing an affordability crisis. Furthermore, the Institute of Medicine (IOM) estimates that 20-30% of healthcare expenditure produces no net benefit. It is vital to establish processes for ensuring that the available funds are spent on care that is appropriate (in line with evidence- or consensus-based guidelines) and for phasing out care that is not. Understanding, for the first time, the level of appropriate care delivered to children in Australia is the focus of research lead by the Australian Institute of Health Innovation (AIHI) at Macquarie University called “CareTrack Kids”.

CareTrack Kids follows AIHI’s landmark CareTrack Australia study, published in the Medical Journal of Australia in 2012, which found that adult Australians receive appropriate care in just 57% of their encounters with healthcare professionals for 22 common conditions. Two other such comprehensive national studies (12, 13) undertaken in the United States by researchers based at RAND, turned up similar results for adults and children. However, data was collected for these studies in the years 1998-2000, meaning the results are now out-of-date.

In addition, the team will examine the frequency and nature of adverse events involving children. Again, this is a first for Australia. Recent paediatric adverse event studies have been undertaken in Canada, England, Norway, and the United States. These types of studies allow priorities to be set on where improvement efforts should be targeted to reduce harm to children.

We intend to study 16 common paediatric conditions such as asthma, diabetes, upper respiratory tract infections, gastroenteritis, and attention deficit hyperactivity disorder (ADHD). We are firstly developing sets of specific and measurable indicators against which to measure appropriate care. The indicators are derived and extracted from clinical practice guidelines. An innovative approach, a wiki, is being using to gain consensus from experts across the country. The wiki is a cost-effective and efficient method of gaining consensus from experts, who may be time-poor and geographically dispersed. The wiki allows for multiple independent rounds of comments and voting, collation and review by a moderator, and conflicts of interest to be managed.

We will then use a convenience sample drawn from three Australian States (Queensland, New South Wales, and South Australia) to access records of healthcare providers (general practitioners, paediatricians, emergency departments (EDs), inpatient-care teams, community centres, and child psychologists). 6,000-8,000 retrospective medical record reviews will be undertaken using trained surveyors.

We will also collect data on adverse events (AEs) using a modified version of the Global Trigger Tool (GTT). The GTT was initially developed by the Institute of Healthcare Improvement (IHI) in 2003 for use in hospitals, and has been modified for primary care in the United Kingdom and North America. GTTs use a series of triggers to screen the medical record for a potential adverse event. The presence of a trigger then leads to a more in-depth review of the record. AEs are then coded according to their type and an incident rate is calculated.

Related Links:
1. Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study
2. Australian Institute of Health Innovation (AIHI)
3. Canadian Association of Paediatric Health Centres (CAPHC) -  Paediatric Practice Guidelines Collaborative
4. CareTrack: assessing the appropriateness of health care delivery in Australia
5. CareTrack Australia
6. CareTrack Kids
7. Children's Hospital of Philadelphia (CHOP) - Clinical Pathways
8. Children’s Hospitals’ Solutions for Patient Safety - Hospital Resources
9. IHI Global Trigger Tool for Measuring Adverse Events
10. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool
11. Preventing Health Care-Associated Harm in Children
12. The Quality of Ambulatory Care Delivered to Children in the United States
13. The Quality of Health Care Delivered to Adults in the United States
14. Risky Business Conference Talk - "Walking a tightrope: balancing standardization of care with minimizing cognitive bias"
15. Royal Children's Hospital Melbourne - Clinical Practice Guidelines
16. Seattle Children's Hospital - Clinical Standard Work Pathways & Tools