Assessing the appropriateness of the management of upper respiratory tract infection in Australian children: a population-based sample survey

OBJECTIVE:To assess the proportion of Australian children aged 0-15 years that received care in line with clinical practice guidelines (CPGs) for upper respiratory tract infections (URTIs). DESIGN:Retrospective medical record review using a multistage sampling strategy. SETTING:General practices, hospital emergency departments and hospital inpatient service providers in three Australian states. PARTICIPANTS:Children aged up to 15 years who received care for URTI in 2012 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary assessment was estimated adherence with 14 indicators of appropriate care as documented in medical records. Indicators were extracted from national and international CPGs and ratified by experts. Secondary assessment was adherence to two bundles of indicators (diagnostic symptoms and medical history taking), where all indicators must be adherent for the bundle to be scored as adherent. RESULTS:There were 1653 children with one or more assessments of URTI care to CPG adherence. Over half of the children were under 3 years of age, with roughly equal numbers of males and females. Three indicators had fewer than 25 visits so were not reported. Overall adherence ranged from 0.5% for 'documented advice around antibiotics' to 88.3% for 'documentation of medical history'. Adherence with Bundle A (documentation of all three definitive symptoms) was 43.1% (95% CI 32.8% to 54.0%) and Bundle B (documentation of all four indicators of medical history) was 30.2% (95% CI 20.9% to 40.9%). CONCLUSIONS:URTIs in children are common, usually self-limiting, conditions that are allocated considerable resources. The results suggest that there may be a need for more thorough holistic assessment of the patient and improved documentation. Since inappropriate prescription of antibiotics for URTIs is still a known problem in Australia, there is a need for consistent, clear communication around antibiotics' lack of impact on symptoms and a high association with undesirable side effects.Janet C Long, Helena M Williams, Shefali Jani, Gaston Arnolda, Hsuen P Ting, Charlotte J Molloy ... et al

CareTrack Aged: the appropriateness of care delivered to Australians living in residential aged care facilities: a study protocol

INTRODUCTION:The aged population is increasing rapidly across the world and this is expected to continue. People living in residential aged care facilities (RACFs) represent amongst the sickest and frailest cohort of the aged population, with a high prevalence of chronic conditions and complex comorbidities. Given the vulnerability of RACF residents and the demands on the system, there is a need to determine the extent that care is delivered in line with best practice ('appropriate care') in RACFs. There is also a recognition that systems should provide care that optimises quality of life (QoL), which includes support for physical and psychological well-being, independence, social relationships, personal beliefs and a caring external environment. The aims of CareTrack Aged are to develop sets of indicators for appropriate care and processes of care for commonly managed conditions, and then assess the appropriateness of care delivered and QoL of residents in RACFs in Australia. METHODS AND ANALYSIS:We will extract recommendations from clinical practice guidelines and, using expert review, convert these into sets of indicators for 15 common conditions and processes of care for people living in RACFs. We will recruit RACFs in three Australian states, and residents within these RACFs, using a stratified multistage sampling method. Experienced nurses, trained in the CareTrack Aged methods ('surveyors'), will review care records of recruited residents within a 1-month period in 2019 and 2020, and assess the care documented against the indicators of appropriate care. Surveyors will concurrently assess residents' QoL using validated questionnaires. ETHICS AND DISSEMINATION:The study has been reviewed and approved by the Human Research Ethics Committee of Macquarie University (5201800386). The research findings will be published in international and national journals and disseminated through conferences and presentations to interested stakeholder groups, including consumers, national agencies, healthcare professionals, policymakers and researchers.Peter D Hibbert, Louise K Wiles, Ian D Cameron, Alison Kitson, Richard L Reed, Andrew Georgiou ... et al

Clinical indicators for common paediatric conditions: processes, provenance and products of the CareTrack Kids study

BACKGROUND:In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities. METHODS:Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care. RESULTS:From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit). CONCLUSION:A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.Louise K. Wiles, Tamara D. Hooper, Peter D. Hibbert, Charlotte Molloy, Les White ... Helena Williams ... et al

Spontaneous ventilation pneumothorax

W. B. Runciman, P. D. Hibber

Transition metal-directed self-assembly of calix[4]arene based dithiocarbamate ligands

The transition metal-directed self-assembly of dithiocarbamate ligand functionalised upper and lower rim calix[4]arenes affords novel dimeric bimetallic bis(calix[4]arene) species as determined by a combination of analytical methods including X-ray crystallography. An exception is a zinc(II) dithiocarbamate upper rim calix[4]arene assembly which is monomeric in nature. Electrochemical investigations reveal the bimetallic copper(II) bis(calix[4]arene) systems can electrochemically sense dihydrogen phosphate and carboxylate anions via significant cathodic perturbations of the respective copper(II)/(III) dithiocarbamate oxidation wave

Assessing the appropriateness of the management of gastro-oesophageal reflux in Australian children: a population-based sample survey

Gastro-oesophageal reflux (GOR) is a common physiological state in infants and young children, with gastro-oesophageal reflux disease (GORD) its pathological manifestation. Management of GOR/GORD requires elimination of possible underlying causes, parental reassurance, modification of feeding and symptom mitigation, monitoring, and referral to paediatricians if warning signs are present. Published clinical practice guidelines (CPGs) seek to support clinicians and improve management. This study aimed to measure the proportion of Australian GOR/GORD paediatric care that was in line with CPG recommendations. National and international CPGs for GOR/GORD were systematically identified and candidate indicators extracted; a Delphi process selected 32 indicators relevant to Australian paediatric care in 2012 and 2013. Medical records were identified in General Practices, the offices of general paediatricians, Emergency Departments and inpatient settings. Adherence to indicators was assessed by nine trained paediatric nurses undertaking retrospective medical record review. Medical records were reviewed in 115 healthcare sites; identifying 285 children, three-quarters aged < 1 year, who had 359 visits for management of GOR/GORD; 2250 eligible indicator assessments were performed. Estimated adherence rates are reported for 21 indicators with ≥ 25 assessments. Five indicators recommending differential diagnostic tests (e.g., urinalysis) for infants presenting with recurrent regurgitation and poor weight gain had ~ 10% adherence; conversely, avoidance of unrecommended tests (e.g., barium swallow and meal) was high (99.8% adherence: 95% CI 97.0-100). Avoidance of prescription of acid-suppression medication for infants at the first presentation was higher if they were healthy and thriving (86.9% adherence: 95% CI 86.0-96.8), intermediate if they had feeding refusal (73.1%: 95% CI 56.0-86.3) and lower if they presented with irritability and unexplained crying (58.8%: 95% CI 28.2-85.0). A guideline targeting Australian health professionals caring for infants and children with GOR/GORD is warranted, highlighting the importance of differential diagnostic testing and avoidance of acid-suppression medication in infants.Gaston Arnolda, Harriet Hiscock, David Moore, Glen Farrow, Peter D. Hibbert, Louise K. Wiles ... et al

Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study

Background: People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. Objective: In this study (CareTrack Aged, CT Aged), we aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes in aged care. Methods: Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multiround modified Delphi process to develop a consensus on what constitutes appropriate care. Results: From 139 CPGs, 5609 recommendations were used to draft 630 indicators. Clinical experts (n=41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity and sleep. Conclusions: The suite of CT Aged clinical indicators can be used for research and assessment of the quality of care in individual facilities and across organizations to guide improvement and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.Peter D Hibbert, Charlotte J Molloy, Louise K Wiles, Ian D Cameron, Leonard C Gray, Richard L Reed, Alison Kitson, Andrew Georgiou, Susan J Gordon, Johanna Westbrook, Gaston Arnolda, Rebecca J Mitchell, Frances Rapport, Carole Estabrooks, Gregory L Alexander, Charles Vincent, Adrian Edwards, Andrew Carson-Stevens, Cordula Wagner, Brendan Mccormack, Jeffrey Braithwait

What Constitutes “Appropriate Care” for Low Back Pain?

Study Design. Multiround wiki-based Delphi expert panel survey. Objective. To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on ‘‘appropriate care’’ for the assessment, diagnosis, and acute, and ongoing care of people with low back pain (LBP). Summary of Background Data. The provision of inappropriate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recommendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to ‘‘appropriate care.’’ Methods. Draft ‘‘appropriate care’’ clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts’ comments and incorporated feedback into the next iteration of the draft indicators. Results. From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 ‘‘appropriateness’’ indicators. In total, 17 experts reviewed these indicators over 18months. The final set of 27 indicators comprised screening and diagnostic processes (n¼8), assessment (n¼3), acute (n¼5), and ongoing care (n¼9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n¼21, 78%), with the remainder focused on care to be avoided.Conclusion. These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of ‘‘appropriate care’’ for LBP.Louise K. Wiles, PhD, B. Physio, Hons, Peter D. Hibbert, PhD, Jacqueline H. Stephens, PhD, Charlotte Molloy, BBehavSc, Psych, Hons, Chris G. Maher, PhD, Rachelle Buchbinder, PhD, GLorimer Moseley, DSc, Peter B. O, Sullivan, PhD, Ivan Lin, PhD, Andrew M. Briggs, PhD, Helen Slater, PhD, Ian A. Harris, PhD, Stephen Jan, PhD, Andrew Dwyer, FRANZCR, Kieran Fallon, MSpExSc, MHE, FRACGP, FACSEP, SFHEA, Malcolm Hogg, MBBS, Kal Fried, MBBS, Chris Needs, FRACGP, Petrina Casey, PhD, Roya Dabestani, MBChB, Debra Kay, PSM, Jeffrey Braithwaite, PhD, and William B. Runciman, Ph

Oblate bands in A approximately 200 bismuth nuclei

The nuclei 198-200Bi were populated via the 186W(19F,xn)198-200Bi reaction at beam energies of 115 MeV and 105 MeV. Another experiment, aimed at investigating the high-spin-level structure of 203,204Bi, used the 198Pt(11B,xn) reaction at a beam energy of 74 MeV. Five new Delta I=1 rotational structures, consisting of stretched magnetic dipole transitions, have been observed. One of these bands is assigned to 198Bi, one to 199Bi, two to 200Bi, and one to 203Bi. The behaviour of the dynamic moments of inertia of these oblate bands is compared with other bands in neighbouring Pb and Bi nuclei