Key findings
This is the first known attempt to develop and validate preventive care quality indicators and apply them in general medical practice to measure adherence. We found on average that less than half of all indicator assessments resulted in the provision of recommended preventive care. When assessed as clinical care bundles, estimated GP performance was above this average when providing immunisations and undertaking anthropometric measurements, and below for assessments of nutrition, parental concerns, developmental progress and behaviour, cardiovascular status, the musculoskeletal system and vision. Estimated adherence to CPGs was highest for the complete bundle of preventive care delivered to 24-month-old children and lowest for those aged 4 months.
Our findings are broadly consistent with similar studies which assessed recommended preventive care for adults in Australia (42%) [
24] and the USA (54.9%) [
26]. Despite considerable efforts to promote and facilitate the uptake of CPGs in Australia [
2,
6], and the importance of early detection of disease with associated reductions in morbidity and mortality, paediatric preventive care is in line with CPGs less than half the time in both developed and developing health systems [
27].
In our study, for the years 2012–2013, recommended preventive care was delivered to Australian children less often than the overall estimate of 59.8% across 17 common medical conditions in the CTK study [
6]. It was similar to that reported for preventive care services delivered to American children between 1996 and 2000 (38.3% ‘well-child care’) [
7].
Documented compliance with the ‘visual assessment bundle’ was found in less than one in five records. This is the first known measure of paediatric preventive eye care and a potentially concerning finding, given that one in ten Australian children aged 0 to 14 years has a vision disorder [
28]. Recommended musculoskeletal examinations also demonstrated low compliance in our CTK population (24.4%; 95% CI 13.1–39.1). While the prevalence of musculoskeletal conditions in children aged less than 4 years of age who present to Australian primary care is estimated at less than 2% [
29], given the volume of paediatric consultations in general practice, this nevertheless represents a significant number of children [
30]. A complete musculoskeletal assessment has additional benefits as it may predict or detect other conditions in young children early to facilitate prompt initiation of treatment, such as cerebral palsy [
31] and torticollis [
32].
Documented compliance with recommended developmental progress and behaviour examinations in our study was substantially less than that reported in related literature. For example, assessment of developmental milestones ranged from 49.9% (no electronic medical record or structured well-baby visit record) to 80.3% (use of the Rourke Baby Record (RBR)) [
33] for children aged up to 22 months, and 68% in a study where paediatric primary care practices collected their own data [
17]. While not directly comparable, the findings suggest lower CTK compliances may be due to differing age distributions of sample populations [
33] and clinical contexts, where the imminent commencement of a 9-month intervention to implement American Academy of Pediatrics recommendations for developmental screening and referrals may have raised awareness of the problem [
17]. Discrepancies in compliance with recommended nutrition assessments (38.5% in CTK, 69.8% in [
33]) may reflect disparate sample age groups.
Documented compliance was highest with the ‘immunisation’ bundle, with approximately four in five children receiving the recommended care. This is higher than rates reported in two studies from the USA that used comparable data collection methods. In a 2007 study [
7], only 49.8% of children were fully immunised, but CTK did not follow infants longitudinally. In a 2015 study [
34], it was reported that 78.4% of newborns and 56% of infants and toddlers were up-to-date with their immunisation status. On the other hand, higher rates of immunisation coverage have been reported in other primary care settings, including New Zealand (95.8%) [
35] and Belgium (96.6–99.5%) [
36]. The variation in immunisation rates between studies might be because of sampling considerations (i.e. a single-site vs the CTK population-based survey) [
35], different data sources (e.g. electronic vaccine ordering and registration system vs CTK medical record audits) [
36], specific vaccinations [
36] and true inter-country differences [
34,
36]. Another consideration may be that our CTK study did not formally evaluate the timeliness of vaccination [
35,
36]; while a range of age groups (ages 2, 4, and 6 months and 2 and 4 years) were covered by our set of IQs, we did not specifically gather data on compliance with immunisation schedules for children between the ages of 6 months and 2 years, or those aged 3 years. This means that if CTK children had experienced delays in their immunisation but vaccines were complete by the ages of 2 or 4 years, our IQs still considered vaccinations to have been delivered on schedule [
37].
Implications and next steps
Barriers to the provision of well-child healthcare have been proffered by Australian GPs and include time constraints, the financial status of families in lower socioeconomic groups who may not be able to cover gap payments, a lack of knowledge around the availability of and access to paediatric services, and fragmented care as a result of poor interflow of information among healthcare providers [
2]. Shortfalls in the financial recompense available to GPs who provide preventive paediatric or ‘well-child’ care may be an additional barrier [
38]; the
Healthy Kids Check [
39] which was operational during the study period enabled a national government rebate (Medicare) to be claimed by GPs only when a child was 4 years of age and had an up-to-date patient history, a complete immunisation schedule and been given a health promotion booklet [
40]. However, the Check was retired in 2015 due to underperformance, cost blowouts and duplication of state and territory-based programs [
41]. There are many potential interventions and initiatives to address barriers and improve preventive care [
42], but success is variable, context-dependent and, too often, not rigorously assessed [
43‐
49]. It is unlikely that any single intervention aimed at improving quality of care will yield significant or sustained benefits, and there is a need to engage, empower and support parents of children with knowledge of the importance, and availability of, resources for preventive health in early childhood to help to optimise preventive care for young children [
2,
42,
50,
51]. Two of the key requirements for future interventions are therefore standards and reliable metrics—both components are potentially provided by this study.
Lack of agreed definitions and established clinical standards of what constitutes recommended (or quality) preventive care is a barrier to best practice. Internationally agreed standards on well-child management and preventive care would allow comparison between healthcare systems and facilitate evaluation of the effectiveness of interventions. The Royal Australian College of General Practitioners (RACGP) have produced a national CPG for preventive activities in children and young people [
52]. The development and implementation of guideline recommendations as measurable standards is strongly advocated as a means by which to initially audit and then ultimately improve quality of care [
2,
24,
53].
A way forward could be the use of integrated e-health medical records embedded with clinical standards to help facilitate the provision of recommended care, consistency and completeness of documentation and enable large-scale surveillance or regionally based audits of current practice as well as for responsiveness to national initiatives to improve healthcare [
24]. Future initiatives and interventions must target practitioners and consumers (paediatric patients and their parents) to optimise individual patient outcomes in addition to process measures.
Strengths and limitations
The key strength of the CTK study is that it was designed to be representative of a broad segment of the Australian population rather than a convenience or purposive sample. However, we did not collect sociodemographic data or randomly select all medical records to be reviewed; records were only sampled if they were identified as having a consultation for one of 17 common paediatric conditions covering approximately 40% of GP consultations with children. This sampling method could bias our estimates, if the sampled conditions are correlated with the quality of preventive care. Therefore, our results are only strictly generalisable to children who have one or more of the 17 conditions sampled in CTK at some point in the 2-year period of interest. This approach was used, rather than selecting another random sample of children without one of the 17 CTK conditions, to minimise the workload on administrative staff at participating general practices who were tasked with generating de-identified lists of eligible children and facilitating surveyor access of their records.
We included only GP records and occasions of service (including care provided by general practice nurses). Our findings therefore do not reflect the quality of preventive care delivered by other types of primary care clinicians. For example, children receiving immunisations from community child-health clinic nurses were not captured in this study as their treatment may not have been documented in general practice records [
54]. In Australia, GPs are the predominant provider of paediatric vaccination services delivering nearly three-quarters of all vaccinations for children aged 0–6 years, which is in addition to being regularly contracted by State Governments to deliver the childhood vaccination programs provided through schools and community centres [
55]. An investigation of the quality of preventive care provided to older children would be an important focus of future research as no other primary care clinicians provide well-child care for this age group. Integrated e-health medical records which record both GP and ‘maternal and child health’ data would facilitate the feasibility of such an endeavour.
The IQs were drawn from one CPG relevant to Australian general practice in 2012–2013, which limits the applicability of the IQs to other contexts and settings. Six clinical experts (three within the CTK team and three external to it) participated in the Delphi process to develop the IQs. This may have adversely affected the face validity of ‘preventive care’ IQs. The IQs, which were developed and validated using rigorous methods to measure compliance, measure most, but not all, aspects of preventive care for children aged from 2 months to 4 years. Age group bundles will have lower compliance scores than clinical care bundles because the former are linked by ‘AND’ statements; compliance with an age group bundle cannot be higher than the compliance for the IQ with the lowest compliance. Clinical care bundles, on the other hand, are weighted averages of all the component indicators assessed. The use of bundles as composite measures in addition to individual IQs provide an alternative perspective on care quality [
56].
Our findings provide a snapshot in time, and compliance rates may have changed since 2013. Despite considerable investment in developing and disseminating comprehensive clinical practice guidelines [
52], the latest Australian Research Alliance for Children and Youth (ARACY) report card suggests that some outcomes (e.g. immunisation against measles and whooping cough) have worsened since the last report in 2013 [
57]. The CTK study has relied on process (rather than outcome-based) indicators to audit care as documented within the medical record. Previous research has suggested that medical records may underestimate the quality of care provided by healthcare services, with doctors being more likely to document some aspects of care (e.g. medication, immunisations) than others in medical records (e.g. patient history information provided to patients) [
58,
59]. The record review method depends on the quality of clinical records and surveyor characteristics; however, we sought to pre-emptively address this by using a two-stage structured record review method, training and testing surveyors prior to data collection and providing a coding manual.