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Refereed/Peer-reviewed Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

Background Integrated care is a model recognised internationally, however, there is limited evidence about its usability in the community. This study aimed to elicit community and provider views about integrated care and how implementation could meet their healthcare needs in a new hospital. Methods Using a qualitative approach, consumer and provider views on the strengths, barriers and enablers for integrated care were collected via a series of online workshops and supplementary interviews. Results A total of 22 consumers and 49 providers participated in 11 focus groups; all perceived integrated care to be an accessible and efficient model that offers a high level of care which enhanced staff and patient well-being. Providers expressed concerns about longer waiting times and safety risks associated with communication gaps and insufficient staff. Enablers include supporting consumers in navigating the integrated care process, co-ordinating and integrating primary care into the model as well as centralising patient electronic medical records. Discussion Primary, tertiary and community linkages are key for integrated care. Successful interoperability of services and networks requires an investment in resources and infrastructure to build the capability for providers to seamlessly access information at all points along the patient pathway. Conclusion Integrated care is perceived by consumers and providers to be a flexible and patient-focused model of healthcare that offers benefits for a hospital of the future.

Refereed/Peer-reviewed Clinical relevance: Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery. Background: To determine the appropriateness of and barriers to glaucoma care by optometrists. Methods: A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care. Results: Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14(38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms. Conclusion: Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

There is anecdotal evidence that the rate of complaints and claims against doctors is rising, yet little is known about (Q1) which types of patients are more likely to make a complaint or claim, nor about (Q2) what interventions are effective in reducing rates of complaints and claims and increasing patient satisfaction. This Evidence Check aimed to answer those two questions. The evidence base for both of the questions was of low quality, with only five studies having a comparison group. Twenty-five studies addressed Question 1. The only patient characteristic to have a consistent effect on rates of complaints and claims was having a mental, behavioural or developmental disorder. Other patient characteristics, including those related to their therapeutic context, had inconsistent or weak relationships with rates of complaints and claims. Twenty studies addressed Question 2 (including one which addressed both questions). There were consistently reduced rates of complaints and claims following implementation of risk management programs and also implementation of communication and resolution programs. Peer feedback programs consistently improved doctors’ response to complaints and subsequent performance. However, the results found here should be interpreted with caution, as the risk of bias inherent in the study designs makes them more likely to erroneously demonstrate an effect.

Purpose\ud Health policy in England has advocated the use of primary care clinicians at emergency departments to address pressures from rising attendances. This study explored senior managers’ perspective son funding mechanisms used to implement the policy and experiences of success or challenges in introducing GPs in or alongside emergency departments.\ud \ud Methods\ud The perspectives of senior clinical, business and finance managers with responsibility for emergency department services and on-site primary care service implementation were investigated in semi-structured interviews with 31 managers at 12 type-1 emergency departments in England and Wales (February 2018 - September 2019). Emergency departments operated one of three GP models or had prior experience of implementing a GP model. Interviews were thematically analysed.\ud \ud Results\ud Perceived successful GPs models in emergency departments were reliant on well-organised and unified funding mechanisms, appropriate staffing and governance, and consideration of population demands and needs. Funding mechanisms and the flow of funds were reported as complex, especially in Inside-parallel GP models. The most efficient mechanisms were described at departments where funding was unified, in collaboration with health and community care services. Staffing with local, experienced GPs was important. There were cautions from experiences with private locum providers.\ud \ud Conclusion\ud Our findings contribute to debates about implementing policy on how primary care clinicians are effectively and safely deployed in emergency departments and how local context should be considered.

Pre-exposure prophylaxis (PrEP) involves HIV negative individuals taking antiretroviral drugs to reduce the probability of infection if exposed and is available through the IMPACT trial in England. This study aimed to explore men who have sex with men (MSM) and service provider (SP) perspectives on provision and accessibility of PrEP in Northern and Central England. Twenty MSM and 25 SPs from four Northern cities and one city in the West Midlands region were recruited for semi-structured interviews (December 2018 to October 2019). Interviews were analysed using Interpretative Phenomenological Analysis (IPA). Three key themes emerged: "Self-sourcing PrEP"; "Service delivery learnings"; and "Impact of using PrEP". Problems with equity of access and accessibility were noted, and recommendations for the future of PrEP programming and equitable service delivery were also presented. The study highlighted divergence in PrEP service experience from patients and providers, with results informing policy, practice and professional training.

To meet the needs of an ageing population and optimise health expenditure, delivery of care should be based on evidence. However, the level of evidence-based care delivered to patients with eye conditions is rarely assessed. This study thus aimed to determine the percentage of eyecare encounters at which a sample of adult Australians received appropriate care (i.e., eyecare in line with evidence-based or consensus-based guidelines). Methods: A cross-sectional retrospective review of optometry practice records was conducted using random stratified (by state) sampling in mainland Australia. Eighty-five clinical indicators were developed from evidence-based clinical practice guideline recommendations and refined by panels of experts using a modified Delphi process. Healthcare records of patients 18 years and over were examined against these indicators, representing appropriate care for three common eye conditions (preventative eyecare, glaucoma, and diabetic eyecare). Encounters occurred in optometry practices that were selected to be representative of the socioeconomic profile of Australian practices. The primary outcome measure was percentage compliance of eyecare delivery against the clinical indicators. Results: From 426 optometry practices contacted by mail or telephone, 90 (21%) replied, 46 proved eligible and 42 were included in the study and visited for data collection. From these 1260 patient records were reviewed. Appropriate eyecare was received by Australian patients at an average of 71% (95%CI 70%, 73%) of eligible encounters. The percentage of appropriateness of eyecare at the condition level for preventative, glaucoma and diabetic eyecare was 81% (95%CI 79%, 83%), 63% (95%CI 61%, 64%), and 69% (95%CI 66%, 73%), respectively. Appropriateness of eyecare delivery was lowest for the domains of history taking and physical examination for all eye conditions. Conclusions: There were pockets of excellence but consistent delivery of appropriate eyecare needs improvement, and gaps in eyecare delivery should be addressed. Refereed/Peer-reviewed

Introduction Studies indicate that women who have sex with women (WSW) report greater levels of drug use than heterosexual women, but globally few studies have looked at sexualised drug use among WSW. This study investigated the factors associated with drug use and sexualised drug use (SDU) among WSW. Methods Potential participants across the UK were invited to take part in a cross-sectional anonymous online survey between April-June 2018. The LGBT Sex and Lifestyles Survey recruited participants through Facebook advertising and social media posts from community organisations. Multivariate logistic regression was used to compare WSW who had engaged in any drug use in the past 12 months with those who had not, and those who engaged in sexualised drug use in the past 12 months with those who engaged in other drug use. Results 1501 WSW could be included in the analyses (mean age = 28.9, 97% white ethnicity). Any drug use was reported by 39% of WSW (n = 583), 44% of which (17% of total, n = 258) reported SDU. Factors associated with drug use were identifying as queer (aOR = 1.86, 95%CI 1.08, 3.23), younger age (aOR = 0.96, 95%CI 0.95, 0.98), being born outside the UK (aOR = 1.75, 95%CI 1.15, 2.66), recent sexual assault (aOR = 2.35, 95%CI 1.43, 3.86), > = 5 female sexual partners (aOR = 3.81, 95%CI 1.81, 8.01), and psychological distress (aOR = 1.75, 95%CI 1.15, 2.67). SDU was associated with identifying as bisexual (aOR = 2.55, 95%CI 1.69, 3.86), > = 5 female sexual partners (aOR = 4.50, 95%CI 1.91, 10.59), and highest education achieved at 16 or lower (aOR = 2.46, 95%CI 1.24, 4.90). Conclusions Some WSW may have negative experiences in relation to drug use and SDU. Harm reduction and health services that provide services for WSW should be aware of potentially compounding factors related to drug use, such as sexual assault and psychological distress, providing a safe and LGBT-friendly environment to discuss these issues.

ObjectivesTrans people remain an understudied population in the UK, with unmet sexual health needs. The aim of this research was to identify possible barriers and facilitators for sexual health clinic attendance and HIV testing among trans people.MethodsLesbian, gay, bisexual and transgender (LGBT) participants from across the UK were invited to take part in a cross-sectional online survey through Facebook advertising (April–June 2018). Psychosocial and sexual factors associated with recent sexual health clinic attendance, and ever having an HIV test were examined using multivariate logistic regression.ResultsA total of 3007 cisgender and 500 trans participants completed the survey. Trans participants were less likely to attend a sexual health clinic than cisgender participants (27% vs 36%, pConclusionsTrans people were less likely to attend sexual health services than cisgender people, and half of trans participants who reported condomless anal intercourse had never had an HIV test. Further research is needed to understand and improve uptake of sexual health services among trans people.

Background Falls are frequent among older adults and have significant health and economic consequences. There have been few studies on the epidemiology of falls in residential aged care facilities (RACFs). Objective To determine the incidence of falls in RACFs using longitudinal routinely collected incident data over 5 years (July 2014–December 2019). Methods A retrospective cohort study is conducted using fall incident data from 25 RACFs in Sydney, NSW, Australia. Incidents relating to a population of 6163 aged care residents aged ≥65 years were included. Outcome measures were incidents of all falls, injurious falls and falls requiring hospitalization. The risk-adjusted incidence rate (IR) for each outcome indicator for each of the 25 facilities was calculated. Results A total of 27 878 falls were reported over 3 906 772 resident days (a crude rate of 7.14 incidents per 1000 resident days; 95% confidence interval (CI) 6.81–7.48). Of these, 10 365 (37.2%) were injurious and 2733 (9.8%) required hospitalization. The crude IRs were 2.65 incidents per 1000 resident days (95% CI 2.53–2.78) for injurious falls and 0.70 incidents per 1000 resident days (95% CI 0.66–0.74) for falls requiring hospitalization. The incidence of falls was significantly higher in respite compared to permanent residents for all falls (adjusted IR ratio (aIRR) 1.33; 95% CI 1.18–1.51) and injurious falls (aIRR 1.30; 95% CI 1.14–1.48) and for men compared to women for all outcomes (all falls aIRR 1.69; 95% CI 1.54–1.86; injurious falls aIRR 1.87; 95% CI 1.71–2.04 and falls requiring hospitalization aIRR 1.29; 95% CI 1.12–1.48). The risk-adjusted IRs per 1000 resident days between facilities varied substantially (all falls 0.57–12.93 falls; injurious falls 0.25–4.47 and falls requiring hospitalization 0.10–1.70). Conclusion Falls are frequent in RACFs, often resulting in injury and hospitalization. The study provides robust and comprehensive information that may help inform future initiatives to minimize the incidence of falls in RACFs.

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, 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 18 months. A final set of 27 indicators comprising screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 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.Level of Evidence: 4.

ObjectiveTo understand how the emerging public health issue of chemsex relates to broader patterns of sexualised drug use (SDU) among men who have sex with men (MSM), which has been understudied.MethodsPotential participants were invited to take part in an anonymous, cross-sectional online survey through Facebook advertising and community organisations’ social media posts (April–June 2018). Multivariable logistic regression was used to compare MSM who engaged in recent SDU (past 12 months) with those who did not, and those who engaged in chemsex (γ-hydroxybutyrate/γ-butyrolactone, crystal methamphetamine, mephedrone, ketamine) with those who engaged in other SDU (eg, poppers, cocaine, cannabis).ResultsOf the 1648 MSM included, 41% reported recent SDU; 15% of these (6% of total, n=99) reported chemsex. Factors associated with SDU were recent STI diagnosis (aOR=2.44, 95% CI 1.58 to 3.76), sexual health clinic attendance (aOR=2.46, 95% CI 1.90 to 3.20), image and performance-enhancing drug use (aOR=3.82, 95% CI 1.87 to 7.82), greater number of condomless anal male partners, lower satisfaction with life and greater sexual satisfaction. Predictors of chemsex compared with other SDU were not being UK-born (aOR=2.02, 95% CI 1.05 to 3.86), living in a densely populated area (aOR=2.69, 95% CI 1.26 to 5.74), low sexual self-efficacy (aOR=4.52, 95% CI 2.18 to 9.40) and greater number of condomless anal male partners. Living with HIV, taking pre-exposure prophylaxis (PrEP), and experiencing or being unsure of experiencing sexual contact without consent were significantly associated with SDU and chemsex in bivariate analyses but not in the multivariable.ConclusionHealth and behavioural differences were observed between MSM engaging in chemsex, those engaging in SDU and those engaging in neither. While some MSM engaging in chemsex and SDU appeared content with these behaviours, the association with life satisfaction and sexual self-efficacy indicates psychosocial support is needed for some. The association with sexual risk and sexual consent also indicates the importance of promoting harm reduction among this population (eg, condoms, PrEP, drug knowledge).

Objectives: We provide the first estimate of HIV prevalence among trans and gender‐diverse people living in England and compare outcomes of people living with HIV according to gender identity.\ud Methods: We analysed a comprehensive national HIV cohort and a nationally representative self‐reported survey of people accessing HIV care in England (Positive Voices). Gender identity was recorded using a two‐step question co‐designed with community members and civil society. Responses were validated by clinic follow‐up and/or self‐report. Population estimates were obtained from national government offices.\ud Results: In 2017, HIV prevalence among trans and gender‐diverse people was estimated at 0.46–4.78 per 1000, compared with 1.7 (95% credible interval: 1.6–1.7) in the general population. Of 94 885 people living with diagnosed HIV in England, 178 (0.19%) identified as trans or gender‐diverse. Compared with cisgender people, trans and gender‐diverse people were more likely to be London residents (57% vs. 43%), younger (median age 42 vs. 46 years), of white ethnicity (61% vs. 52%), under psychiatric care (11% vs. 4%), to report problems with self‐care (37% vs. 13%), and to have been refused or delayed healthcare (23% vs. 11%). Antiretroviral uptake and viral suppression were high in both groups.\ud Conclusions: HIV prevalence among trans and gender‐diverse people living in England is relatively low compared with international estimates. Furthermore, no inequalities were observed with regard to HIV care. Nevertheless, trans and gender‐diverse people with HIV report poorer mental health and higher levels of discrimination compared with cisgender people.

Over the past two decades, prominent researchers such as Greenhalgh [1], Plsek [2], Leykum [3], Lanham [4], Petticrew [5] and Hawe [6, 7] and their colleagues and teams have promoted using complexity theory to describe and analyse the various dimensions of healthcare organisation [8–12]. Internationally, in parallel, governments have recognised the need to ‘think differently’ about healthcare policy and service delivery, but without much traction on how that might be done and what it might mean. Nevertheless, it has now become more common—but by no means universal—to apply a complexity lens to understanding healthcare services and to improving them. This involves greater appreciation of elaborate, intricate, multi-faceted care networks, healthcare ecosystems, layered parts in composite settings, contextual differences across care settings, clinical cultures, multi-agent environments, and the convoluted, challenging, wicked problems [13] these systems throw up. However, with some relatively limited exceptions, the quality and safety fields’ interest in complexity has, to date, been largely superficial, both theoretically and empirically [1].

Introduction Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM). Although the recent focus on chemsex is a reflection of the associated harms it is important to understand SDU more broadly and its associations with risk behaviours. Additionally, some of the reasons suggested for MSM engagement in SDU are also likely to apply to women who have sex with women (WSW) and trans people. The aim of this review was to investigate SDU, including chemsex, among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual health outcomes (HIV status, STI diagnosis, condom use). Methods Papers that were published between January 2010 and June 2020 reporting SDU in MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and Web of Science. Results were synthesised using a narrative approach. Results The search identified 2,710 publications, of which 75 were included in the final synthesis. The majority of studies measured SDU among MSM (n = 71), and four studies measured SDU among trans people. Research into SDU had been conducted in 55 countries and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs used to define chemsex varied. Among studies that researched MSM, SDU was most commonly investigated in relation to condomless anal intercourse (n = 42), followed by HIV prevalence (n = 35), and then STI diagnoses (n = 27). Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies. Conclusions SDU research is lacking among WSW and trans people, despite trans women having a high HIV prevalence. Among MSM, most drugs were associated with sexual health outcomes, and therefore it is important to include both chemsex drugs and other drugs in SDU research.

Asthma is the most common chronic condition of childhood. Self-management is integral to good asthma control. This qualitative paper explores how children with asthma and their parents perceive asthma, their experience with asthma, and how they manage symptoms, preventions and medications within and outside the home. We undertook 15 focus groups with 41 school-aged (6–11 years) children with asthma and 38 parents. Parents and their children attended the same focus groups. We used thematic analysis to analyse the transcripts. Our findings show the impact asthma can have on children’s social and emotional wellbeing and highlight how reliant school-aged children are on their parents to effectively manage their asthma. Parents reported being unsure when their child’s symptoms warranted visiting their doctor or hospital. Schools were identified as a source of difficulty regarding asthma management; families reported that children may be self-conscious about their asthma and using their inhaler at school. School policies and teachers’ lack of asthma knowledge were reported to exacerbate children’s reluctance to use their inhaler at school. Our results have implications for the design and implementation of children’s self-management interventions for their asthma, particularly when they are at school and away from their parents.

Background Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU. Method Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis. Results MSM participants had a median age of 34 years (range 23–66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare. Conclusion SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.

Residents in Australian aged care facilities can suffer serious preventable harm from incidents (‘adverse events’ (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring. Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations. Refereed/Peer-reviewed

Refereed/Peer-reviewed Objective: This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients. Methods: Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design. Results: Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication. Conclusions: The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

Previous research has focused on acceptability of pre-exposure prophylaxis (PrEP) use, but few community-based studies have been conducted regarding actual use, and PrEP use in the context of sexualised drug use remains understudied. A national online cross-sectional study recruited men who have sex with men (MSM) via social media (April–June 2018). Multivariable logistic regression was used to investigate factors associated with PrEP use. Bivariate analyses compared engaging in condomless anal intercourse (CAI) under the influence of specific drugs and recent sexually transmitted infection (STI) diagnoses (past 12 months) between MSM taking PrEP and those not. Overall, 6% (99/1581) MSM reported current PrEP use. Factors associated with PrEP use were increasing age, recent genitourinary medicine (GUM) attendance (95% versus 45%, aOR = 6.25, 95%CI 2.05, 19.03), an HIV test in the past three months (89% versus 23%, aOR = 14.22, 95%CI 6.76, 29.90), and recent engagement in chemsex (21% versus 4%, aOR = 3.56, 95%CI 1.78, 7.11). MSM taking PrEP were more likely to have had an STI diagnosis (42% versus 8%), most commonly chlamydia (26% versus 3%) and gonorrhoea (25% versus 4%). Considering the elevated levels of self-reported STI diagnoses among those on PrEP, there was a high level of engagement with sexual health services, which may help reduce onward STI transmission.

Background: At times of increasing pressure on emergency departments, and the need for research into different models of service delivery, little is known about how to recruit patients for qualitative research in emergency departments. We aimed to collect evidence on patients’ experiences of different models using general practitioners in emergency departments. Challenges were faced at all stages of patient recruitment, from identifying and inviting eligible patients, consenting them for participation, and finally to engaging them in interviews. Methods: By analysing processes, amendments and outcomes of recruitment methods, as well as conducting a thematic analysis of field-notes taken during research visits, this paper aimed to describe the factors which influenced patient recruitment in the GPs in EDs study, and make recommendations based on our learning. Results: We found the following factors influenced the success of patient recruitment in the emergency department setting: complicated or time-consuming electronic health record systems for identifying patients; narrow participant eligibility criteria; limited NHS research nurse support; and lack of face-to-face communication between researchers and eligible patients. Conclusions: This paper adds to the growing evidence for improving patient recruitment in different settings, with a particular focus on qualitative research in emergency departments. Our findings have implications for future studies attempting to recruit patients in similar settings.

Beyond identifying and counting the things that go wrong, understanding how and why they go wrong requires qualitative research, especially for low-frequency events. The purpose of this study was to identify and characterize patient safety and quality issues related to health information technology (HIT) in medical imaging by collecting and analyzing incident reports through the lens of thematic analysis. In this article, we analyze 5 clusters: Staff related issues (16%), issues with diagnosis (15%), HIT incidents that involved 'paper record' (12%), information and communication related (4%), and 'action taken' related issues (4%). Human factors involved people failing to scan forms into the computer system (consents, requests, bookings, questionnaires, assessments, treatments and prescriptions), and another 4% involved failure to enter verbally imparted information into the system (about infectious patients, cancelled cases, and the status of reports). All of these problems had their genesis in human errors and violations. Human factors were found to cause more deleterious effects than technical factors. Of three instances of deaths caused by diagnostic issues, two were triggered by human factors, missed diagnosis. However, 'staff or organizational outcome' was evenly distributed for both human and technical factors. It was therefore important to identify and characterize these incidents related to health information technology in medical imaging through the lens of thematic analysis, to provide a basis for improvements in preventing issues and improving clinical practice Refereed/Peer-reviewed

PurposePatient safety failures are recognised as a global threat to public health, yet remain a leading cause of death internationally. Vulnerable children are inversely more in need of high-quality primary health and social-care but little is known about the quality of care received. Using national patient safety data, this study aimed to characterise primary care-related safety incidents among vulnerable children.MethodsThis was a cross-sectional mixed methods study of a national database of patient safety incident reports occurring in primary care settings. Free-text incident reports were coded to describe incident types, contributory factors, harm severity and incident outcomes. Subsequent thematic analyses of a purposive sample of reports was undertaken to understand factors underpinning problem areas.ResultsOf 1183 reports identified, 572 (48%) described harm to vulnerable children. Sociodemographic analysis showed that included children had child protection-related (517, 44%); social (353, 30%); psychological (189, 16%) or physical (124, 11%) vulnerabilities. Priority safety issues included: poor recognition of needs and subsequent provision of adequate care; insufficient provider access to accurate information about vulnerable children, and delayed referrals between providers.ConclusionThis is the first national study using incident report data to explore unsafe care amongst vulnerable children. Several system failures affecting vulnerable children are highlighted, many of which pose internationally recognised challenges to providers aiming to deliver safe care to this at-risk cohort. We encourage healthcare organisations globally to build on our findings and explore the safety and reliability of their healthcare systems, in order to sustainably mitigate harm to vulnerable children.

The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Background The use of image and performance enhancing drugs (IPEDs) among men who have sex with men (MSM) and women who have sex with women (WSW) is rarely studied, with most of this research focused on anabolic androgenic steroid use among MSM. To address this gap, the extent of recent IPED use and the associated factors are explored in a community-recruited sample of MSM and WSW Methods Data from the UK LGBT Sex and Lifestyles Survey was used, which recruited through social-media advertising and community organisations (April-June 2018). Participants were asked if they had taken any IPEDs (e.g. anabolic steroids, growth hormone, hCG, Melanotan, non-prescribed diet pills) in the past 12 months. Factors associated with recent (in past 12 months) IPED use among MSM and WSW were investigated using stepwise binary logistic regression. Results 1,658 MSM and 1,507 WSW were included in the analysis. Among MSM, 3.4% (n = 57) had recently taken IPEDs, 60% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among MSM was associated with psychoactive drug use, Viagra use, higher body dissatisfaction, and lower sexual satisfaction. Among WSW, 4.1% (n = 62) had recently taken IPEDs, and 50% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among WSW was associated with being aged 45 years and over, recent STI diagnosis, recent sexual contact without consent, and higher body dissatisfaction. Conclusion IPED use was reported by around 1-in-25 MSM and WSW, and was associated with a number of health and psychological problems. Research to better understand the drivers and impacts of IPED use among MSM and WSW, and how this compares to use among heterosexual people is needed.

BackgroundRecent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aimed to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in EDs. We explored perceptions of whether patients were perceived to be appropriately streamed to emergency care, primary care, other hospital services or community primary care services; and effects on patient flow (waiting times and length of stay in the ED); and safe streaming outcomes.MethodsWe used realist evaluation methodology to explore perceived streaming effectiveness. We visited 13 EDs with different primary care service models (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.ResultsWe identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory (cognitive continuum theory) with our findings to recommend a focus for training nurses in streaming and service improvements.ConclusionsWe identified key mechanisms relating to the effectiveness of primary care streaming in different models of service. We recommend a collaborative approach to service development, guidance and training (including input from ED clinicians and primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.

BackgroundEvidence from evaluations of emergency departments (EDs) with co-located primary care services suggests that they influence additional demand for non-urgent care (provider-induced demand). In a realist review of the literature on the effects of primary care services in EDs we proposed a theory that when primary care services are distinct at an ED they may encourage additional primary care demand and when primary care clinicians work indistinctly in the ED there is no additional demand. We aimed to explore evidence for this theory and explain contexts, mechanisms and outcomes that influence such demand.MethodsWe used realist evaluation methodology and carried out observations of key processes. We interviewed 23 patients, 21 ED clinical directors, 26 other ED staff members and 26 GPs at 13 EDs (England & Wales). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to provider induced demand.ResultsEDs with distinct primary care services were perceived to attract more demand for primary care than EDs where primary care clinicians worked indistinctly because the primary care service was visible, widely known about, enabled direct access, and received NHS 111 referrals. Other influences on demand were patients’ experiences of accessing primary care, the capacity for urgent care in the community, location of the ED and public transport links, service design and developments (new buildings, renovations) and population characteristics (unfamiliarity with local healthcare services, not registered with a GP or different cultural perceptions of seeking health care).ConclusionsA range of patient, local-system and wider-system factors contribute to additional demand at an ED with co-located primary care services. Our findings can inform providers and policymakers in developing strategies to limit the effect of these influences on additional demand.

Aims/Objectives/BackgroundRecent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aim to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in emergency departments. We explored whether patients were appropriately streamed to emergency care, primary care, other hospital services or community primary care services; patient flow (including effects on waiting times and length of stay in the emergency department); and safe streaming outcomes. We sought suggestions for quality improvements relating to streamingMethods/DesignA realist evaluation methodology was used to explore perceived streaming effectiveness. We visited 13 emergency departments (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses).Field notes from observations and audio-recorded interviews were transcribed verbatim and were analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.Results/ConclusionsWe identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory with our findings to recommend a focus for training nurses in streaming and service improvements. We recommend a collaborative approach to service development, guidance and training (including input from emergency department clinicians, primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.

Retrospective medical record review to assess compliance with low back pain (LBP) care indicators. To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings. LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings. A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators (“CareTrack”). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010. Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%–98%). Allied health practitioners and hospitals were the most compliant (82%–83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction. Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified. Level of Evidence: N /A

© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. Background: older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting. Objectives: to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care. Design and Setting: a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013. Subjects: 1,591 primary care patient safety incident reports regarding patients aged 65 years and older. Methods: we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care. Results: the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm). Conclusion: priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.

Objective: We examine the prevalence of quality care (as measured by adherence to recommendations in clinical practice guidelines) for Australian paediatric patients (⩽15 years) with depression and/or anxiety, using data from the CareTrack Kids study; a population-based study of the quality of healthcare practice in inpatient and ambulatory healthcare settings. Methods: A multistage stratified sample identified records of 6689 children. Of these, 156 records were identified for depression and 356 for anxiety. These were assessed for adherence to 15 depression and 13 anxiety indicators, respectively, using a review of medical records. Results: Adherence to assessment and management guidelines was low for both conditions: assessment bundle (depression = 33%, 95% confidence interval = [20, 48]; anxiety = 54%, 95% confidence interval = [43, 64] and depression management bundle = 35%, 95% confidence interval = [15, 60]). Across both conditions, the highest adherence was recorded for indicators that addressed prescription of medications (e.g. venlafaxine, 100%; benzodiazepines, 100%; selective serotonin reuptake inhibitor, 94% and antidepressants, 91%), while compliance was the lowest for ensuring children with depression had an emergency safety plan (44%), informing parents of the risks and benefits of prescribed anxiety medication (51%) and assessment for other causes (59% for depression; 68% for anxiety). Conclusion: These findings suggest that strategies are needed to improve guideline adherence for mental health disorders in children and adolescents, particularly among general practitioners. Learning from these indicators could inform clinical prompts in electronic medical records, as well as links to additional information, to assist in decision-making and streamline work practices.

Objective To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. Design A qualitative content analysis of root cause analysis investigation reports. Setting Public health services in Victoria, Australia, 2010–2015. Participants Incidents of retained surgical items as described by 31 root cause analysis investigation reports. Main Outcome Measure(s) The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. Results Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. Conclusion Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

Background & Aims: Opioid substitution treatment is used in many countries as an effective\ud harm minimization strategy. There is a need for more information about patient safety\ud incidents and resulting harm relating to this treatment. We aimed to characterise patient\ud safety incidents involving opioid-substitution treatment with methadone or buprenorphine in\ud community-based care by: (i) identifying the sources and nature of harm, and (ii) describing\ud and interpreting themes to identify priorities to focus future improvement work.\ud Design: Mixed-methods study examining patient safety incident reports involving opioid\ud substitution treatment with either methadone or buprenorphine in community-based care.\ud Setting: Data submitted between 2005 and 2015 from the National Reporting and Learning\ud System (NRLS), a national repository of patient safety incident reports from across England\ud and Wales.\ud Participants: 2,284 reports were identified involving patients receiving community-based\ud opioid substitution treatment.\ud Measurements: Incident type, contributory factors, incident outcome and severity of harm.\ud Analysis involved data coding, processing and iterative generation of data summaries using\ud descriptive statistical and thematic analysis.\ud Findings: Most risks of harm from opioid substitution treatment came from failure in one of\ud four processes of care delivery: prescribing opioid-substitution (n=151); supervised\ud dispensing (n=248); non-supervised dispensing (n=318); and monitoring and communication\ud (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing\ud (n=91/127, 72%). Staff- (e.g. slips during task execution, not following protocols) and\ud organisation-related (e.g. poor working conditions or poor continuity of care between\ud services) contributory factors were identified for over half of incidents.\ud 3\ud Conclusions: Risks of harm in delivering opioid-substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid-substitution, supervised dispensing, non-supervised dispensing, and monitoring and communication.

Objective Healthcare accreditation surveyors are well positioned to gain access to hospitals and apply their existing data collection skills to research. Consequently, we contracted and trained a surveyor cohort to collect research data for the Deepening our Understanding of Quality in Australia (DUQuA) project. The aim of this study is to explore and compare surveyors’ perceptions and experiences in collecting quality and safety data for accreditation and for health services research. Design A qualitative, comparative study. Setting and Participants Ten surveyors participated in semi-structured interviews, which were audio recorded, transcribed and coded using Nvivo11. Interview transcripts of participants were analysed thematically and separately, providing an opportunity for comparison and for identifying common themes and subthemes. Intervention(s) None. Main Outcome Measure(s) Topics addressed data collection for healthcare accreditation and research, including preparation and training, structure, organization, attitudes and behaviours of staff and perceptions of their role. Results Five themes and ten subthemes emerged from the interviews: (1) overlapping facilitators for accreditation and research data collection, (2) accreditation-specific facilitators, (3) overlapping barriers for accreditation and research data collection, (4) research data collection-specific barriers and (5) needs and recommendations. Subthemes were (1.1) preparation and training availability, (1.2) prior knowledge and experiences; (2.1) ease of access, (2.2) high staff engagement, (3.1) time, (4.1) poor access and structure, (4.2) lack of staff engagement, (4.3) organizational changes; (5.1) short-notice accreditation and (5.2) preparation for future research. Conclusions Although hospital accreditation and research activities require different approaches to data collection, we found that suitably trained accreditation surveyors were able to perform both activities effectively. The barriers surveyors encountered when collecting data for research provide insight into the challenges that may be faced when visiting hospitals for short-notice accreditation.

Objective The Deepening our Understanding of Quality in Australia (DUQuA) project is a multisite, multi-level, cross-sectional study of 32 of the largest hospitals in Australia. This overview examines relationships between (i) organization-level quality management systems and department-level quality management strategies and (ii) patient-level measures (clinical treatment processes, patient-reported perceptions of care and clinical outcomes) within Australian hospitals. Design We examined hospital quality improvement structures, processes and outcomes, collecting data at organization, department and patient levels for acute myocardial infarction (AMI), hip fracture and stroke. Data sources included surveys of quality managers, clinicians and patients, hospital visits, medical record reviews and national databases. Outcomes data and patient admissions data were analysed. Relationships between measures were evaluated using multi-level models. We based the methods on the Deepening our Understanding of Quality Improvement in Europe (DUQuE) framework, extending that work in parts and customizing the design to Australian circumstances. Setting, participants and outcome measures The 32 hospitals, containing 119 participating departments, provided wide representation across metropolitan, inner and outer regional Australia. We obtained 31 quality management, 1334 clinician and 857 patient questionnaires, and conducted 2401 medical record reviews and 151 external assessments. External data via a secondary source comprised 14 460 index patient admissions across 14 031 individual patients. Associations between hospital, Emergency Department (ED) and department-level systems and strategies and five patient-level outcomes were assessed: 19 of 165 associations (11.5%) were statistically significant, 12 of 79 positive associations (15.2%) and 7 of 85 negative associations (8.2%). Results We did not find clear relationships between hospital-level quality management systems, ED or department quality strategies and patient-level outcomes. ED-level clinical reviews were related to adherence to clinical practice guidelines for AMI, hip fracture and stroke, but in different directions. The results, when considered alongside the DUQuE results, are suggestive that front line interventions may be more influential than department-level interventions when shaping quality of care and that multi-pronged strategies are needed. Benchmark reports were sent to each participating hospital, stimulating targeted quality improvement activities. Conclusions We found no compelling relationships between the way care is organized and the quality of care across three targeted patient-level outcome conditions. The study was cross-sectional, and thus we recommend that the relationships studied should be assessed for changes across time. Tracking care longitudinally so that quality improvement activities are monitored and fed back to participants is an important initiative that should be given priority as health systems strive to develop their capacity for quality improvement over time.

Background Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts’ practice and to describe the methods used to measure appropriateness of eye care. Methods A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts’ practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974. Results Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2–100% for glaucoma, 0–100% for diabetic retinopathy and 0–100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery. Conclusions These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives. Electronic supplementary material The online version of this article (10.1186/s12913-019-4493-3) contains supplementary material, which is available to authorized users.

Objective To determine the extent to which care received by Australian children presenting with croup is in agreement with Clinical Practice Guidelines (CPGs). Design Retrospective population-based sample survey. Croup clinical indicators were derived from CPGs. Data sources/study setting Medical records from three healthcare settings were sampled for selected visits in 2012 and 2013 in three Australian states. Data collection Data were collected by nine experienced paediatric nurses, trained to assess eligibility for indicator assessment and adherence to CPGs. Surveyors undertook criterion-based medical record reviews using an electronic data collection tool. Results Documented guideline adherence was lower for general practitioners (65.9%; 95% CI: 60.8–70.6) than emergency departments (91.1%; 95% CI: 89.5–92.5) and inpatient admissions (91.3%; 95% CI: 88.1–93.9). Overall adherence was very low for a bundle of 10 indicators related to assessment (4.5%; 95% CI: 2.4–7.6) but higher for a bundle of four indicators relating to the avoidance of inappropriate therapy (83.1%; 95% CI: 59.5–96.0). Conclusions Most visits for croup were characterized by appropriate treatment in all healthcare settings. However, most children had limited documented clinical assessments, and some had unnecessary tests or inappropriate therapy, which has potential quality and cost implications. Universal CPG and clinical assessment tools may increase clinical consistency.

ObjectivesThe CareTrack study found that a wide range of appropriateness of care (ie, care in line with evidence-based or consensus-based guidelines) was delivered across many health conditions in Australia. This study therefore aimed to demonstrate the feasibility of using the CareTrack method (a retrospective onsite record review) to measure the appropriateness of eye care delivery.DesignCross-sectional feasibility study.Setting and participantsTwo hundred and thirteen patient records randomly selected from eight optometry and ophthalmology practices in Australia, selected through a combination of convenience and maximum variation sampling.MethodsRetrospective record review designed to assess the alignment between eye care delivered and 93 clinical indicators (Delphi method involving 11 experts) extracted from evidence-based clinical practice guidelines.Primary outcome measureNumber of eligible patient records, sampling rates and data collection time. This feasibility study also tested the ability of 93 clinical indicators to measure percentage appropriate eye care for preventative, glaucoma and diabetic eye care. A secondary outcome was the percentage of practitioner–patient encounters at which appropriate eye care was received.ResultsA median of 20 records (range 9 to 63) per practice were reviewed. Data collection time ranged from 3 to 5.5 hours (median 3.5). The most effective sampling strategy involved random letter generation followed by sequential sampling. The appropriateness of care was 69% (95% CI 67% to 70%) for preventative eye care, 60% (95% CI 56% to 58%) for glaucoma and 63% (95% CI 57% to 69%) for diabetic eye care.ConclusionsAppropriateness of eye care can be measured effectively using retrospective record review of eye care practices and consensus-based care indicators.

Background: Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. The identification of improved ways of delivering palliative care outside working hours is a priority area for policymakers. Aim: To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary-care services outside normal working hours. Design: A mixed-methods cross-sectional analysis of patient safety incident reports from the National Reporting and Learning System. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Setting/participants: A total of 1072 patient safety incident reports involving patients receiving sub-optimal palliative care via the out-of-hours primary-care services. Results: Incidents included issues with: medications (n = 613); access to timely care (n = 123); information transfer (n = 102), and/or non-medication-related treatment such as pressure ulcer relief or catheter care (n = 102). Almost two-thirds of reports (n = 695) described harm with outcomes such as increased pain, emotional, and psychological distress featuring highly. Commonly identified contributory factors to these incidents were a failure to follow protocol (n = 282), lack of skills/confidence of staff (n = 156), and patients requiring medication delivered via a syringe driver (n = 80). Conclusion: Healthcare systems with primary-care-led models of delivery must examine their practices to determine the prevalence of such safety issues (communication between providers; knowledge of commonly used, and access to, medications and equipment) and utilise improvement methods to achieve improvements in care.

Objective To assess General Practitioner (GP) and pediatrician adherence to clinical practice guidelines (CPGs) for diagnosis, treatment and management of attention deficit hyperactivity disorder (ADHD). Method Medical records for 306 children aged ≤15 years from 46 GP clinics and 20 pediatric practices in Australia were reviewed against 34 indicators derived from CPG recommendations. At indicator level, adherence was estimated as the percentage of indicators with ‘Yes’ or ‘No’ responses for adherence, which were scored ‘Yes’. This was done separately for GPs, pediatricians and overall; and weighted to adjust for sampling processes. Results Adherence with guidelines was high at 83.6% (95% CI: 77.7–88.5) with pediatricians (90.1%; 95% CI: 73.0–98.1) higher than GPs (68.3%; 95% CI: 46.0–85.8; p = 0.02). Appropriate assessment for children presenting with signs or symptoms of ADHD was undertaken with 95.2% adherence (95% CI: 76.6–99.9), however ongoing reviews for children with ADHD prescribed stimulant medication was markedly lower for both pediatricians (51.1%; 95% CI: 9.6–91.4) and GPs (18.7%; 95% CI: 4.1–45.5). Conclusion Adherence to CPGs for ADHD by pediatricians was generally high. Adherence by GPs was lower across most domains; timely recognition of medication side effects is a particular area for improvement.

Review question/objective:The objective of this review is to find the best available evidence regarding effectiveness of quality improvement interventions in clinical radiology and the experiences and perspectives of staff and patients. More specifically, the review questions are:How effective are t

Martin Basedow,1 Peter Hibbert,1 Tamara Hooper,1 William Runciman,1 Adrian Esterman,2 1School of Psychology, Social Work and Social Policy, 2School of Nursing and Midwifery, University of South Australia, Adelaide, SA, Australia Objective: The aim of this study was to evaluate the satisfaction of Australian patients who suffer from osteoarthritis (OA) with their health care providers and the perceived helpfulness of treatments and information sources. Methods: A self-administered questionnaire was conducted with a sample of 560 Australian patients who suffer from OA with questions about satisfaction with health care providers and the helpfulness of different treatment options and information sources. Logistic regression models were used to assess potential predictors of satisfaction. Thematic analysis was undertaken for attitudinal factors associated with satisfaction. Results: A total of 435 participants returned questionnaires (response rate 78%). Most respondents were highly satisfied with the care provided by their general practitioner (GP) (84%), communication with their GP (88%), time spent with their GP (84%), and their ability to talk freely with their GP about their medical problem (93%), but less satisfied with their ability to talk freely about associated emotional problems (77%). Satisfaction with pharmacists (80%), rheumatologists (76%), and orthopedic surgeons (72%) was high. Joint replacement surgery (91%), prescription anti-inflammatory medications (66%), aids and assistive devices (65%), intra-articular injections (63%), and prescription painkiller medications (62%) were perceived as effective treatments. Less highly rated treatments were exercise (48%), physiotherapy (43%), and complementary medicines (29%). A majority of patients were satisfied with the information to manage their OA (65%). From the multivariable logistic regression analysis, four GP satisfaction factors were found to be predictors of overall satisfaction with GP care: the amount of time that the GP spends with the patient (P=0.005), the information the GP provides about what to expect (P

Introduction: Although incident reporting systems are widespread in health care as a strategy to reduce harm to patients, the focus has been on reporting incidents rather than responding to them. Systems containing large numbers of incidents are uniquely placed to raise awareness of, and then characterize and respond to infrequent, but significant risks. The aim of this paper is to outline a framework for the surveillance of such risks, their systematic analysis, and for the development and dissemination of population-based preventive and corrective strategies using clinical and human factors expertise. Requirements for a population-level response: The framework outlines four system requirements: to report incidents; to aggregate them; to support and conduct a risk surveillance, review and response process; and to disseminate recommendations. Personnel requirements include a non-hierarchical multidisciplinary team comprising clinicians and subject-matter and human factors experts to provide interpretation and high-level judgement from a range of perspectives. The risk surveillance, review and response process includes searching of large incident and other databases for how and why things have gone wrong, narrative analysis by clinical experts, consultation with the health care sector, and development and pilot testing of corrective strategies. Criteria for deciding which incidents require a population-level response are outlined. Discussion: The incremental cost of a population-based response function is modest compared with the ‘reporting’ element. Combining clinical and human factors expertise and a systematic approach underpins the creation of credible risk identification processes and the development of preventive and corrective strategies. Refereed/Peer-reviewed

Background: Head injuries in children are a common and potentially devastating presentation. The Care Track Kids (CTK) study assessed care of Australian children aged 0–15 years, in 2012 and 2013, to evaluate the proportion in line with guideline-based indicators for 17 common conditions. Overall adherence to guideline-based recommended practice occurred 59.8% of care encounters (95% CI: 57.5–62.0), and 78.3% (95% CI: 75.1–81.2) for head injury. This paper presents results for head injury, at indicator level. Methods A modified version of the RAND-UCLA method of indicator development was used. Indicators, measurable components of a standard or guideline, were developed from international and national guidelines relating to head injury in children and were ratified by clinical experts using a Delphi process. Paediatric nurses extracted data from medical records from general practitioners (GPs), emergency departments (EDs) and inpatient wards in Queensland,New South Wales and South Australia, for children under 15 years receiving care in 2012–13. Our purpose was to estimate the percentage adherent for each indicator. Results: The medical records of 629 children with head injury were examined. Fifty-one percent of children were under 5 years old, with more males (61%) than females. Thirty-eight indicators were assessed. Avoidance of nasotracheal airways (100%; 95% CI: 99.4–100) or nasogastric tubes (99.7%; 95% CI: 98.5–100) for children with a head injury had the highest adherence. Indicators relating to primary and secondary assessment of head injuries were mostly adhered to. However, adherence to other indicators was poor (e.g., documentation of the past history of children (e.g., presence or absence of seizures) before the injury;29.9% (95% CI: 24.5–35.7)), and for others was difficult to estimate with confidence due to small sample sizes (e.g., Children with a head injury who were intubated had PaO2 above 80mm Hg; 56.0% (95% CI: 28.6–80.9)). Indicators guiding clinical decision making regarding the need for CT scan had insufficient data to justify reporting. Conclusion: This study highlights that management of head injury in children mostly follows guidelines,but also flags some specific areas of inconsistency. Individual sites are encouraged to use these results to guide investigation of local practices and inform quality improvement endeavours. usc Refereed/Peer-reviewed

This study aimed to operationalise and use the World Health Organisation's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). Over two-thirds (69.0%) of incidents occurred during treatment and 27.4% occurred in the operating theatre. Clinical process and procedures (55.9%), medication/IV fluids (11.2%) and healthcare-associated infection/complications (10.4%) were the most common incident types. Coroners made recommendations in 44.0% of deaths and organisations undertook preventive actions in 40.0% of deaths. This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths. Further testing of the mICPS is warranted.

Objective: The aims of this study were twofold: (1) to design and validate a set of clinical indicators of appropriate care for tonsillitis and (2) to measure the level of tonsillitis care that is in line with guideline recommendations in a sample of Australian children Study design: A set of tonsillitis care indicators was developed from available national and international guidelines and validated in 4 stages. This research used the same design as the CareTrack Kids study, which was described in detail elsewhere Setting: Samples of patient records from general practices, emergency departments, and hospital admissions were assessed Subjects and methods: Patient records of children aged 0 to 15 years were assessed for the presence of, and adherence to, the indicators for care delivered in 2012 and 2013 Results: Eleven indicators were developed. The records of 821 children (mean age, 5.0 years; SD, 4.0) with tonsillitis were screened. The reviewers conducted 2354 eligible indicator assessments across 1127 visits. Adherence to 6 indicators could be assessed and ranged from 14.3% to 73.2% (interquartile range 31.5% to 72.2%). Conclusion: Our main findings are consistent with the international literature: the treatment of many children who present with confirmed or suspected tonsillitis is inconsistent with current guidelines. Future research should consider how the indicators could be applied in a structured and automated manner to increase the reliability and efficiency of record reviews and help raise clinicians' awareness of appropriate tonsillitis management. Refereed/Peer-reviewed

Background Patient satisfaction is an important outcome measure guiding quality improvement in the healthcare setting while the patient-centred care movement places increasing importance on patient engagement in clinical decision-making. However, the concept of patient satisfaction is not clearly defined, and beliefs of patients are not always evident in health surveys. Researchers rarely follow up on surveys to explore patient views and what they mean in greater depth. This study set out to examine perceptions of hospital care, through in-depth, qualitative data capture and as a result, to gather rich, patient-driven information on user experience and satisfaction in the Australian healthcare setting; and identify influencing factors. Methods Focus groups were undertaken in four St Vincent’s Health Australia (SVHA) hospitals in 2017 where participants discussed responses to eight questions from the Press Ganey Patient Experience Survey. Thirty people who were inpatients at SVHA. Results Good communication and high-quality information at arrival and discharge were found to be important to patients. Communication breakdown was also evident, further exacerbated by a range of environmental factors such as sharing a room with others. Overall, patients’ felt that while their spiritual needs were well-supported by the hospital staff at all SVHA hospitals, it was the clinical teams prioritised their emotional needs. Good communication and environments can improve patient experience and follow-up at home is vital. Conclusions Patient-centred care needs careful planning with patients involved at entry and exit from hospital. Focused communication, environmental changes, attending to complaints, and clearer discharge strategies are recommended.

Background Although “non-specific” in 90% of cases, low back pain (LBP) is often treated as an independent entity, even though comorbidities are commonly associated with it. There is evidence that some LBP may be related to chronic conditions or be a symptom of poor health. The purpose of this study was to clarify the extent of comorbidities amongst a cohort of Australian adults with LBP and examine if having concurrent conditions has any association with appropriateness of care for LBP. Methods A population-based sample of patients with one or more of 22 common conditions was recruited by telephone; consents were obtained to review their medical records. Trained surveyors extracted information from their medical records to examine the care patients received for their LBP with respect to ten indicators of appropriate care, ratified by LBP experts. Using LBP as the index condition, lists of self-reported comorbidities and those that were documented in medical records were compared. Medical records were reviewed and analysed with respect to appropriateness of care to identify any significant differences in care received between patients with LBP only and those with LBP plus comorbidities. Results One hundred and sixty four LBP patients were included in the analysis. Over 60% of adults with LBP in Australia had one of 17 comorbidities documented, with females being more likely than males to have comorbid conditions (63% vs 37%, p = 0.012). The more comorbidities, the poorer their reported health status (63% vs 30%, p = 0.006). Patients with comorbidities were significantly less likely to receive appropriate LBP care on nine of the ten LBP indicators (p

IMPORTANCE The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. OBJECTIVE To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. DESIGN, SETTING, AND PARTICIPANTS Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4] , acute infection [n = 7], and injury [n = 1] ), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. EXPOSURES Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. MAIN OUTCOMES AND MEASURES Quality of care for each clinical condition and overall. RESULTS Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. 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 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. CONCLUSIONS AND RELEVANCE Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate. Refereed/Peer-reviewed

Background Patients receiving OOH palliative care are at increased risk of unsafe care (Mazzocato & Stiefe, l 1997; Dietz et al. 2010). The identification of improved ways of delivering palliative care outside working hours is a priority area for policy makers. (Best et al. 2015) To allow service redesign to provide safer care for patients, a means of identifying priority areas for systems improvement is needed. Aims Explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary care services outside normal working hours. Review literature to identify existing interventions addressing causes of unsafe care. Engage a stakeholder group in a large healthcare organisation in Wales to identify priority areas within the out–of–hours GP service. Methods We characterised patient safety incident (PSI) reports submitted to the National Reporting and Learning System, using codes to describe what happened, underlying causes, harm outcome, and severity of harm. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Results of this analysis informed a scoping review of the literature (Tricco et al. 2016), and findings were presented as a driver diagram (a one-page summary of where and how to improve the system). Results 1072 reports of suboptimal care, described: medication-related issues (n=613); access to timely care (n=123); and non-medical management of pressure ulcers or urinary catheters. (n=102). Almost two thirds of reports (n=695) described harm with outcomes including increased pain, distress and dying in a place not of their choosing. A scoping review identified interventions to improve confidence of staff around end of life medications, improve advanced care planning and improve documentation across providers. The driver diagram facilitated discussions amongst stakeholders (lay and professional) to contextualise findings and identify priorities for service improvement. Conclusions Analysis of PSI reports and associated literature review can be used to inform service improvement initiatives.