Discussion
This study characterizes the adherence of healthcare provision to CPGs, at a population level, in children with T1DM, aged 0–15 years from 2012 to 2013, restricted to hospital settings and community-based pediatrician visits in three states where 60% of Australian children reside. We have previously reported that children presenting with T1DM, care was consistent with CPG indicators three-quarters of the time (75.8%; 95% CI 66.5 to 83.6).15 Restricted to hospital settings and community pediatricians, the overall estimate was 79.9% (95% CI 69.5 to 88.0). The current analysis demonstrates that, within each care type (diagnosis, routine care and emergency care), adherence was similar across metropolitan and rural geographies and tertiary hospitals. Care was also similar between community pediatricians and hospital settings for indicators relating to routine care. Although the overall rate of adherence was high, there were some important indicators with low adherence.
Children with T1DM have an increased prevalence of behavioral and psychological disorders.19–21 These disorders are predictive of worse long‐term outcomes and decreased quality of life.21 So, it was disappointing to see that only approximately a third of children with suboptimal glycemic control were screened for psychological disorders using a validated tool (indicator 5), although this should be interpreted cautiously as the CI shows a wide range. Few clinicians would challenge the importance of mental health, or the need for screening, but this study highlights it is one of the areas where there is a possible evidence-practice gap. Similarly, few would argue against the provision of sick-day emergency plans (indicators 29 and 30), but this too was an area where the selected professional groups underperformed, with roughly half having a documented plan that included either blood ketone measurement or details on 24 hours access to clinical advice. This group of indicators may be promising targets for local quality improvement activities.
Other indicators with lower adherence may reflect diversity in clinical practice. For example, an indicator about education on carbohydrate counting (indicator 28) had two-thirds adherence (67.7%), possibly reflecting the diversity of views on appropriate insulin management within the specialty.7
Previous studies have assessed the impact on glycemic outcomes for patients attending diabetes clinics in metropolitan versus rural areas but only at a state-based level.22–24 Our study shows that in Australia, in three states containing the majority of the national pediatric population, the care provided at diagnosis, during routine follow-up and in an emergency is comparable regardless of location. We also found that the quality of routine care provided did not differ significantly between pediatricians in the community in comparison to ED or inpatient settings. These are important findings for future healthcare planning, especially considering the geographical isolation of many Australian children and the associated difficulty in accessing tertiary healthcare.
Our study findings, although derived from an Australian setting, are similar to international data. This includes self-reported adherence,8 and prospective cohort studies11 25 from the USA and Canada which assessed adherence to CPGs in the management of children with diabetes. The agreement of findings derived from studies using different methodologies provides greater confidence in the robustness of the result. CTK assessed a broader range of indicators than most. For example, the study by Amed et al11 defined ‘optimal adherence’ as three diabetes-related physician visits/year, three HbA1c tests/year, one glucagon prescription dispensed/year and appropriate screening for diabetes-related comorbidity and complications. This contrasts with the 35 indicators ranging from diagnosis to routine and emergency care assessed in our study.
To our knowledge, only one study has attempted to improve adherence to T1DM practice guidelines in children.26 This novel study found positive effects of a computerized decision aid in a diabetes clinic to improve the rate of screening for diabetes-related complications.26 However, this study was limited by its retrospective evaluation and was only conducted in a single outpatient clinic. Given the increasing prevalence and burden of T1DM, it is surprising that further work in this area has not been performed.
The strength of our study lies in its extensive design in collating indicators from two sets of guidelines, combined with expert review, a comprehensive set of indicators used and large sample size in ED and inpatient settings. The assessment of adherence to CPG recommendations used a standardized, objective, peer-reviewed, quality-controlled format across a variety of healthcare settings and providers. This allowed assessment of the state of healthcare based on objective criteria without bias across multiple jurisdictions.
The study has several limitations. For example, guideline adherence is not always reflective of patient or healthcare provider perspectives on quality of care. A previous study has indicated that non-adherence may be attributed to a variety of reasons such as omission, systems issues or a conscious decision by the treating clinician not follow a particular recommendation.27 Data acquisition in our study was reliant on medical records documentation meaning the full extent of the care provided may not have been captured, potentially leading to an underestimation of actual adherence. Moreover, the study was designed to assess guideline adherence, so we unable to comment on the extent to which adherence correlates with clinical and patient-level outcomes.
Another limitation is that healthcare for pediatric diabetes management is often provided in hospital outpatient clinics. Our sampling strategy only identified 31 visits in 7 of the 84 GPs sampled, so we excluded these from consideration in the current study, and we did not formally sample visits to all hospital outpatient clinics. A post hoc assessment of six children attending outpatient clinic visits in one tertiary hospital in each participating state, using the same indicators and assessed by the same surveyors, revealed an overall estimated adherence rate of 84.7% for 469 routine care indicators, not dissimilar to routine care in tertiary hospitals overall (76.0% from 603 routine care indicators; 95% CI 52.1 to 91.9). Finally, clinical practice is constantly evolving and the clinical practice guidelines we used do not necessarily reflect the latest developments in the field. For example, indicator 23 recommends a 10 mL/kg bolus of 0.9% normal saline for children with severe DKA but recent evidence suggests that this advice may not be superior to alternative fluid regimens; nevertheless, experts recommended this indicator for care in 2012 and 2013.28 Finally, we note that guideline adherence may have changed since 2012–2013. While up-to-date feedback to clinicians would be preferable, health services research at this scale represents a significant logistical exercise resulting in unavoidable delays; the methods can be adapted for more rapid deployment at local level to provide clinicians with prompt feedback for quality assurance purposes.