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Objectives The prevention and management of venous thromboembolism (VTE) is often at variance with guidelines. The CareTrack Australia (CTA) study reported that appropriate care (in line with evidence-based or consensus-based guidelines) is being provided for VTE at just over half of eligible encounters. The aim of this paper is to present and discuss the detailed CTA findings for VTE as a baseline for compliance with guidelines at a population level. Setting The setting was 27 hospitals in 2 states of Australia. Participants A sample of participants designed to be representative of the Australian population was recruited. Participants who had been admitted overnight during 2009 and/or 2010 were eligible. Of the 1154 CTA participants, 481(42%) were admitted overnight to hospital at least once, comprising 751 admissions. There were 279 females (58%), and the mean age was 64 years. Primary and secondary outcome measures The primary measure was compliance with indicators of appropriate care for VTE. The indicators were extracted from Australian VTE clinical practice guidelines and ratified by experts. Participants’ medical records from 2009 to 2010 were analysed for compliance with 38 VTE indicators. Results Of the 35 145 CTA encounters, 1078 (3%) were eligible for scoring against VTE indicators. There were 2–84 eligible encounters per indicator at 27 hospitals. Overall compliance with indicators for VTE was 51%, and ranged from 34% to 64% for aggregated sets of indicators. Conclusions The prevention and management of VTE was appropriate for only half of the at-risk patients in our sample; this provides a baseline for tracking progress nationally. There is a need for national and, ideally, international agreement on clinical standards, indicators and tools to guide, document and monitor care for VTE, and for measures to increase their uptake, particularly where deficiencies have been identified.

For decades, there have been concerns about the extent to which the health system provides the right care to those who need it in a cost-effective, timely manner. In Australia, there has been much discussion¹ and marked improvements in some areas,²⁻⁴ but the provision of highly variable and often inappropriate care remains a nationwide problem.¹,⁵⁻⁷ We designed the CareTrack Australia study to determine the percentage of health care encounters at which Australians receive appropriate care (ie, care in line with evidence-based or consensus-based guidelines).⁸ Key results published in this issue of the Journal demonstrate that, although there are areas of excellent practice, there are also large gaps in the provision of appropriate care.⁹ Such gaps have been identified before,¹,³,⁴ but not in a population-based study across 22 of the most common conditions.⁹ In the long term, there is a clear need to move from oneoff studies such as CareTrack towards making the measurement of appropriateness of care routine and prospective. This would allow the community, health professions and payers such as government to better calibrate their approaches to health services improvement. Here, we discuss the operational lessons of the CareTrack study, identifying barriers to the surveillance of appropriate care, and make recommendations as to how they might be overcome at a national level.

Objective: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence-based or consensus-based guidelines). Design, setting and participants: Computer-assisted telephone interviews and retrospective review of the medical records (for 2009-2010) of a sample of at least 1000 Australian adults to measure compliance with 522 expert consensus indicators representing appropriate care for 22 common conditions. Participants were selected from households in areas of South Australia and New South Wales chosen to be representative of the socioeconomic profile of Australians. Health care encounters occurred in health care practices and hospitals with general practitioners, specialists, physiotherapists, chiropractors, psychologists and counsellors. Main outcome measure: Percentage of health care encounters at which the sample received appropriate care. Results: From 15 292 households contacted by telephone, 7649 individuals agreed to participate, 3567 consented, 2638 proved eligible, and 1154 were included after gaining the consent of their health care providers. The adult Australians in this sample received appropriate care at 57% (95% CI, 54%-60%) of 35 573 eligible health care encounters. Compliance with indicators of appropriate care at condition level ranged from 13% (95% CI, 1%-43%) for alcohol dependence to 90% (95% CI, 85%-93%) for coronary artery disease. For health care providers with more than 300 eligible encounters each, overall compliance ranged from 32% to 86%. Conclusions: Although there were pockets of excellence and some aspects of care were well managed across health care providers, the consistent delivery of appropriate care needs improvement, and gaps in care should be addressed. There is a need for national agreement on clinical standards and better structuring of medical records to facilitate the delivery of more appropriate care. Refereed/Peer-reviewed

Introduction In recent years in keeping with international best practice, clinical guidelines for common conditions have been developed, endorsed and disseminated by peak national and professional bodies. Yet evidence suggests that there remain considerable gaps between the care that is regarded as appropriate by such guidelines and the care received by patients. With an ageing population and increasing treatment options and expectations, healthcare is likely to become unaffordable unless more appropriate care is provided. This paper describes a study protocol that seeks to determine the percentage of healthcare encounters in which patients receive appropriate care for 22 common clinical conditions and the reasons why variations exist from the perspectives of both patients and providers. Methods/design A random stratified sample of at least 1000 eligible participants will be recruited from a representative cross section of the adult Australian population. Participants' medical records from the years 2009 and 2010 will be audited to assess the appropriateness of the care received for 22 common clinical conditions by determining the percentage of healthcare encounters at which the care provided was concordant with a set of 522 indicators of care, developed for these conditions by a panel of 43 disease experts. The knowledge, attitudes and beliefs of participants and healthcare providers will be examined through interviews and questionnaires to understand the factors influencing variations in care. Ethics and dissemination Primary ethics approvals were sought and obtained from the Hunter New England Local Health Network. The authors will submit the results of the study to a relevant journal as well as undertaking oral presentations to researchers, clinicians and policymakers., Article summary Article focus What is the percentage of healthcare encounters at which Australians receive appropriate care? What influences variations in care from the perspectives of patients and healthcare providers? Key messages A protocol for a population-based study of appropriate care of 1000 patients using medical record review. Strengths and limitations of this study Obtaining a snapshot and using a consistent method for 522 indicators across 22 common conditions power diagnostic indicators because they only present once for each patient. The potential attrition rate of healthcare providers and telephone recruitment of participants may introduce selection biases.

Background. Understanding the patient safety literature has been compromised by the inconsistent use of language. Objectives. To identify key concepts of relevance to the International Patient Safety Classification (ICPS) proposed by the World Alliance For Patient Safety of the World Health Organization (WHO), and agree on definitions and preferred terms. Methods. Six principles were agreed upon—that the concepts and terms should: be applicable across the full spectrum of healthcare; be consistent with concepts from other WHO Classifications; have meanings as close as possible to those in colloquial use; convey the appropriate meanings with respect to patient safety; be brief and clear, without unnecessary or redundant qualifiers; be fit-for-purpose for the ICPS. Results. Definitions and preferred terms were agreed for 48 concepts of relevance to the ICPS; these were described and the relationships between them and the ICPS were outlined. Conclusions. The consistent use of key concepts, definitions and preferred terms should pave the way for better understanding, for comparisons between facilities and jurisdictions, and for trends to be tracked over time. Changes and improvements, translation into other languages and alignment with other sets of patient safety definitions will be necessary. This work represents the start of an ongoing process of progressively improving a common international understanding of terms and concepts relevant to patient safety. Keywords: patient safety, definitions, concepts, terminology, classification

Objective Interpretation and comparison of patient safety information have been compromised by the lack of a common understanding of the concepts involved. The World Alliance set out to develop an International Classification for Patient Safety (ICPS) to address this, and to test the relevance and acceptability of the draft ICPS and progressively refine it prior to field testing. Design Two-stage Delphi survey. Quantitative and qualitative analyses informed the review of the ICPS. Setting International web-based survey of expert opinion. Participants Experts in the fields of patient safety, health policy, reporting systems, safety and quality control, classification theory and development, health informatics, consumer advocacy, law and medicine; 253 responded to the first round survey, 30% of whom responded to the second round. Results In the first round, 14% felt that the conceptual framework was missing at least one class, although it was apparent that most respondents were actually referring to concepts they felt should be included within the classes rather than the classes themselves. There was a need for clarification of several components of the classification, particularly its purpose, structure and depth. After revision and feedback, round 2 results were more positive, but further significant changes were made to the conceptual framework and to the major classes in response to concerns about terminology and relationships between classes. Conclusions The Delphi approach proved invaluable, as both a consensus-building exercise and consultation process, in engaging stakeholders to support completion of the final draft version of the ICPS. Further refinement will occur.

Introduction: Clinical quality indicators are necessary to monitor the performance of healthcare services. The development of indicators should, wherever possible, be based on research evidence to minimise the risk of bias which may be introduced during their development, because of logistic, ethical or financial constraints alone. The development of automated methods to identify the evidence base for candidate indicators should improve the process of indicator development. The objective of this study is to explore the relationship between clinical quality indicators for asthma management in children with outcome and process measurements extracted from randomised controlled clinical trial reports. Methods and analysis: National-level indicators for asthma management in children will be extracted from the National Quality Measures Clearinghouse (NQMC) database and the National Institute for Health and Care Excellence (NICE) quality standards. Outcome measures will be extracted from published English language randomised controlled trial (RCT) reports for asthma management in children aged below 12 years. The two sets of measures will be compared to assess any overlap. The study will provide insights into the relationship between clinical quality indicators and measurements in RCTs. This study will also yield a list of measurements used in RCTs for asthma management in children, and will find RCT evidence for indicators used in practice. Ethics and dissemination: Ethical approval is not necessary because this study will not include patient data. Findings will be disseminated through peer-reviewed publications. Refereed/Peer-reviewed

Introduction: Australian and international clinical practice guidelines are available for common paediatric conditions. Yet there is evidence that there are substantial variations between the guidelines, recommendations (appropriate care) and the care delivered. This paper describes a study protocol to determine the appropriateness of the healthcare delivered to Australian children for 16 common paediatric conditions in acute and primary healthcare settings. Methods and analysis: A random sample of 6000-8000 medical records representing a cross-section of the Australian paediatric population will be reviewed for appropriateness of care against a set of indicators within three Australian states (New South Wales, Queensland and South Australia) using multistage, stratified sampling. Medical records of children aged

Aim Healthcare failures have been identified in 26% of UK child deaths. Despite children accounting for 40% of general practitioners’ workload, little is known about the safety of care in the community setting. Using data from a national reporting system, this study aimed to characterise the paediatric safety incidents occurring in general practice to inform a logic model with identified priorities for clinical practice improvement. Methods We undertook a retrospective cross-sectional mixed methods study utilising paediatric reports submitted to the National Reporting and Learning System from general practice (2003–2013). Analysis involved a detailed data coding process using multi-axial frameworks combined with descriptive statistical analysis, and thematic analysis of all reports of severe harm and death. A 20% sample of reports were independantly double coded and kappa statistics of inter-rater reliability were calculated. Using frequency distributions and cross-tabulations the relationships between incident types and contributory factors were explored. Clusters of contributory factors were identified. Subject matter experts identified primary and secondary drivers for improvement. Results 1,788 reports were identified with 763 (42.7%) describing harm to children. Four priority areas–incidents associated with the most harmful outcomes–include errors associated with: medication management; timely referral of unwell children; delivery of safe evidence-based treatment; and, adequate diagnosis and assessment. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. The factors contributing to these incidents form the bases of our recommendations for improvement and are illustrated in a logic model (see Figure 1). Conclusion This is the first analysis of nationally–collected general practice–related paediatric safety incident reports. Recommendations to mitigate harm in these priority areas include: mandatory paediatric training for all general practitioners; utilising electronic tools to support diagnosis, management and referral decision-making; and use of tools such as bar code scanning to reduce medication errors. Practitioners are encouraged to reflect on these recommendations, as well as explore their own local safety report data to identify additional priorities for practice improvement.

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.