Which conditions are treated most in line with CPGs?

little girl at doctor

Australian children receive care within clinical practice guideline recommendations on average 60% of the time, new research has found

But there is considerable variation in adherence to guidelines by clinical condition, the national study by the Australian Institute of Health Innovation at Macquarie University has found.

The CareTrack Kids study, published in the Journal of the American Medical Association, evaluated care for 6689 children under 16 years of age, using 160,202 clinical indicator assessments.

The conditions treated least in line with clinical practice guidelines were tonsillitis, at 43.5%; gastroesophageal reflux disease, at 52.8%; and upper respiratory tract infections, at 53.2% (see below for full list).

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.

In the case of tonsillitis, the prescription of antibiotics was overused as a treatment, while instruction to parents to provide fluids was underused.

“Adherence to quality of care indicators was estimated at 59.8% (95%CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95%CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95%CI, 36.8%-50.4%; n = 2354) for tonsillitis,” the authors write.

“The mean adherence by condition category was estimated as 60.5% (95%CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95%CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95%CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95%CI, 75.1%-81.2%; n = 10 278) for injury.”

“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,” Professor Braithwaite said.

“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.”

An accompanying editorial by David C Grossman from Kaiser Permanente said that while the study had some limitations, the study raises questions around whether it is generalizable outside Australia as well as what accounts for the relatively poor indicator performance across the 17 examined conditions.

“The results likely reflect the performance of systems and not just individual clinicians,” he writes.

“Although clinicians play a key role in decision making, lessons from the primary care medical home and chronic care models teach that clinician behaviour change is not the only determinant nor the only solution for system underperformance.”

Clinicians also want confidence that clinical practice guidelines are supported by strong evidence, he writes.

Associate Professor Alexandra Martiniuk, an NHMRC TRIP Fellow at the University of Sydney and an Honorary Senior Research Fellow at the George Institute for Global Health, said that the study highlights challenges related to clinical practice guidelines, most of which are 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.”

Conditions treated most in line with clinical practice guidelines

Autism – 88.8%

ADHD – 83.6%

Anxiety – 80.8%

Head injury – 78.3%

Diabetes – 75.8%

Depression – 71.5%

Abdominal pain – 69.9%

Croup – 69.8%

Conditions treated least in line with clinical practice guidelines

Tonsillitis – 43.5%

Gastroesophageal reflux disease – 52.8%

Upper respiratory tract infection – 53.2%

Fever – 53.5%

Otitis media (middle ear infections) – 58.0%

Asthma – 58.1%

Eczema – 59.2%

Bronchiolitis – 59.3%

Acute gastroenteritis – 59.6%

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