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Objectives: To examine the role of frailty in risk of re‐hospitalisation and mortality for aged care residents following a fall injury hospitalisation. Methods: Retrospective analysis of linked hospitalisation and aged care data of adults aged ≥65 years residing in aged care. A semi‐competing risk analysis examined risk of hospital readmission. Results: Residents who had intermediate or high frailty, who were aged 70‐79 or 80‐89 years, who had 1‐2 or ≥3 comorbidities, sustained a hip fracture, and who had either low, moderate or high complex health‐care requirements had a higher risk of being readmitted to hospital. Frailty was not associated with mortality for those with no hospital readmission or mortality after readmission. Conclusion: Frailty is an important prognostic factor associated with readmission for residents of aged care hospitalised for a fall injury. Frailty screening could assist to identify people at a high risk of re‐hospitalisation following a fall injury. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective To assess quality of care for children presenting with acute abdominal pain using validated indicators. Design Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages. Setting and participants Medical records of children aged 1-15 years receiving care in 2012-2013 were sampled from 57 general practitioners, 34 emergency departments (ED) and 28 hospitals across three Australian states; 6689 medical records were screened for visits for acute abdominal pain and audited by trained paediatric nurses. Outcome measures Adherence to 21 care quality indicators and three bundles of indicators: bundle AHistory; bundle B-Examination; bundle C- Imaging. Results Five hundred and fourteen children had 696 visits for acute abdominal pain and adherence was assessed for 9785 individual indicators. The overall adherence was 69.9% (95% CI 64.8% to 74.6%). Adherence to individual indicators ranged from 21.6% for assessment of dehydration to 91.4% for appropriate ordering of imaging. Adherence was low for bundle AHistory (29.4%) and bundle B- Examination (10.2%), and high for bundle C- Imaging (91.4%). Adherence to the 21 indicators overall was significantly lower in general practice (62.7%, 95% CI 57.0% to 68.1%) compared with ED (86.0%, 95% CI 83.4% to 88.4%; p<0.0001) and hospital inpatient settings (87.9%, 95% CI 83.1% to 91.8%; p<0.0001). Conclusions There was considerable variation in care quality for indicator bundles and care settings. Future work should explore how validated care quality indicator assessments can be embedded into clinical workflows to support continuous care quality improvement. [ABSTRACT FROM AUTHOR]

Background: Infections caused by antibiotic resistant pathogens are increasing, with antibiotic overuse a key contributing factor.Objective: The CareTrack Kids (CTK) team assessed the care of children in Australia aged 0-15 years in 2012 and 2013 to determine the proportion of care in line with clinical practice guidelines (CPGs) for 17 common conditions. This study analyses indicators relating to paediatric antibiotic overuse to identify those which should be prioritised by antimicrobial stewardship and clinical improvement programs.Method: A systematic search was undertaken for national and international CPGs relevant to 17 target conditions for Australian paediatric care in 2012-2013. Recommendations were screened and ratified by reviewers. The sampling frame comprised three states containing 60% of the Australian paediatric population (South Australia, New South Wales and Queensland). Multi-stage cluster sampling was used to select general practices, specialist paediatric practices, emergency departments and hospital inpatient services, and medical records within these. Medical records were reviewed by experienced paediatric nurses, trained to assess eligibility for indicator assessment and compliance with indicators. Adherence rates were estimated.Results: Ten antibiotic overuse indicators were identified; three for tonsillitis and one each for seven other conditions. A total of 2621 children were assessed. Estimated adherence for indicators ranged from 13.8 to 99.5% while the overall estimate of compliance was 61.9% (95% CI: 47.8-74.7). Conditions with high levels of appropriate avoidance of antibiotics were gastroenteritis and atopic eczema without signs of infection, bronchiolitis and croup. Indicators with less than 50% adherence were asthma exacerbation in children aged > 2 years (47.1%; 95% CI: 33.4-61.1), sore throat with no other signs of tonsillitis (40.9%; 95% CI: 16.9, 68.6), acute otitis media in children aged > 12 months who were mildly unwell (13.8%; 95% CI: 5.1, 28.0), and sore throat and associated cough in children aged < 4 years (14.3%; 95% CI: 9.9, 19.7).Conclusion: The results of this study identify four candidate indicators (two for tonsillitis, one for otitis media and one for asthma) for monitoring by antibiotic stewardship and clinical improvement programs in ambulatory and hospital paediatric care, and intervention if needed. [ABSTRACT FROM AUTHOR]

Background: Head injuries in children are a common and potentially devastating presentation. The CareTrack 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 PaO2above 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. [ABSTRACT FROM AUTHOR]

Aim: Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children.Methods: We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children.Results: We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices.Conclusions: Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME. [ABSTRACT FROM AUTHOR]

Background: Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.Methods: Clinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting.Results: The field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1-54.6), 77.5% (95% CI: 65.3-87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3-79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0-85.8) and 64.7% (95% CI: 57.0-71.9) for children 3-11 months of age, both significantly higher than for children aged 4-15 years (53.5%; 95% CI: 50.0-56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2-80.6) and 76.7% (95% CI: 71.7-81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6-46.1).Conclusions: This study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4-15 years. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to refine and validate a tool to measure safety culture and leadership in Australian hospitals.Design: The clinician safety culture and leadership questionnaire was constructed by combining and refining the following two previously validated scales: Safety Attitudes Questionnaire and the Leadership Effectiveness Survey. Statistical processes were used to explore the factor structure, reliability, validity and descriptive statistics of the new instrument.Setting: Thirty-two large Australian public hospitals.Participants: 1382 clinicians (doctors, nurses and allied health professionals).Main Outcome Measure(s): Descriptive statistics, structure and validity of clinician safety culture and leadership scale.Results: We received 1334 valid responses from participants. The distribution of ratings was left-skewed, with a small ceiling effect, meaning that scores were clustered toward the high end of the scale. Using confirmatory factor analysis, we confirmed the structure of the three scales as a combined measure of safety culture and leadership. The data were divided into equal calibration and validation datasets. For the calibration dataset, the Chi-square: df ratio was 4.4, the root mean square error of approximation RMSEA (a measure of spread of the data) was 0.071, the standardized root mean square residual SRMR (an absolute measure of the fit of the data) was 0.058 and the Confirmatory Fit Index (CFI) (another test confirming the fit of the data) was 0.82; while none of the indices suggested good fit, all but CFI fell within acceptable thresholds. All factors demonstrated adequate internal consistency and construct reliability, as desired. All three domains achieved discriminant validity through cross-loadings, meaning that the three domains were determined to be independent constructs. Results for the validation dataset were effectively identical to those found in the calibration dataset.Conclusions: While the model may benefit from additional refinement, we have validated the tool for measuring clinician safety culture and leadership in our Australian sample. The DUQuA safety culture and leadership scale can be used by Australian hospitals to assess clinician safety culture and leadership, and is readily modifiable for other health systems depending on their needs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

With this paper, we initiate the Supplement on Deepening our Understanding of Quality in Australia (DUQuA). DUQuA is an at-scale, cross-sectional research programme examining the quality activities in 32 large hospitals across Australia. It is based on, with suitable modifications and extensions, the Deepening our Understanding of Quality improvement in Europe (DUQuE) research programme, also published as a Supplement in this Journal, in 2014. First, we briefly discuss key data about Australia, the health of its population and its health system. Then, to provide context for the work, we discuss previous activities on the quality of care and improvement leading up to the DUQuA studies. Next, we present a selection of key interventional studies and policy and institutional initiatives to date. Finally, we conclude by outlining, in brief, the aims and scope of the articles that follow in the Supplement. This first article acts as a framing vehicle for the DUQuA studies as a whole. Aggregated, the series of papers collectively attempts an answer to the questions: what is the relationship between quality strategies, both hospital-wide and at department level? and what are the relationships between the way care is organised, and the actual quality of care as delivered? Papers in the Supplement deal with a multiplicity of issues including: how the DUQuA investigators made progress over time, what the results mean in context, the scales designed or modified along the way for measuring the quality of care, methodological considerations and provision of lessons learnt for the benefit of future researchers. [ABSTRACT FROM AUTHOR]

This final article in our 12-part series articulating a suite of quality improvement studies completes our report on the Deepening our Understanding of Quality in Australia (DUQuA) program of work. Here, we bring the Supplement's key findings and contributions together, tying up loose ends. Traversing the DUQuA articles, we first argued the case for the research, conducted so that an in-depth analysis of one country's health system, completed 5 years after the landmark Deepening our Understanding of Quality Improvement in Europe (DUQuE), was available. We now provide a digest of the learning from each article. Essentially, we have contributed an understanding of quality and safety activities in 32 of the largest acute settings in Australia, developed a series of scales and tools for use within Australia, modifiable for other purposes elsewhere, and provided a platform for future studies of this kind. Our main message is, despite the value of publishing an intense study of quality activities in 32 hospitals in one country, there is no gold standard, one-size-fits-all methodology or guarantee of success in quality improvement activities, whether the initiatives are conducted at departmental, organization-wide or whole-of-systems levels. Notwithstanding this, armed with the tools, scales and lessons from DUQuA, we hope we have provided many more options and opportunities for others going about strengthening their quality improvement activities, but we do not claim to have solved all problems or provided a definitive approach. In our view, quality improvement initiatives are perennially challenging, and progress hard-won. Effective measurement, evaluating progress over time, selecting a useful suite of quality methods and having the persistence to climb the improvement gradient over time, using all the expertise and tools available, is at the core of the work of quality improvement and will continue to be so. [ABSTRACT FROM AUTHOR]

Objective: Patients can provide a unique perspective on the safety of care in hospitals. Understanding that the extent to which the way hospitals are organized for quality and safety is associated with patient perceptions of care is becoming increasingly valued and necessary for the direction of targeted interventions across healthcare systems. The UK-developed patient measure of safety (PMOS) assesses eight domains of ward safety from the patient point of view and has recently been adapted and piloted in Australia. The aim of this study is to test the psychometric properties of PMOS-Australia (PMOS-A) amongst a large cohort of hospitalized patients.Design: Cross-sectional questionnaire validation assessment.Setting and Participants: As part of the DUQuA project, the PMOS-A survey was distributed within acute myocardial infarction, hip fracture and stroke departments across 32 large public hospitals in Australia. Patients could complete the PMOS-A independently, or request the assistance of a family member/guardian, or staff on the wards-space was included to record mode of completion.Main Outcome Measures: Confirmatory factor analysis (CFA) was undertaken on a calibration sample to generate the model, and a validation sample was used to cross-validate the model. A subset of only those participants who received assistance for PMOS-A completion was also tested using CFA on a calibration and validation sample. Model fit indices (chi-square to degrees of freedom ratio [Chi-square:DF], root mean square error of approximation [RMSEA], comparative fit indices [CFI], standardized root mean squared residual [SRMR]), Cronbach's α, average inter-item correlations, construct reliability and cross-loadings were examined with reference to recommended thresholds to establish the extent of convergent validity and discriminant validity. A marker of criterion validity was assessed through testing associations between the PMOS-A and adherence to clinical guidelines.Results: Across the calibration and validation samples of the full (N = 911) and assisted completers only subset (N = 490), three (Chi-square:DF, SRMR, RMSEA) of the four indices consistently or almost always met thresholds for acceptable model fit. CFI indices did not meet the recommended limits (0.72-0.78, against a target > 0.9). Positive relationships were found for all tests between PMOS-A and adherence to clinical guidelines, and these were significant when assessed in the calibration datasets for the full and assisted completion samples.Conclusion: A sufficiently reliable and valid measure of patient perceptions of safety has been developed. These findings should provide adequate support to justify the use of this measure to assess patient perceptions of safety in Australian hospitals and can be modified for use elsewhere. [ABSTRACT FROM AUTHOR]

Background and objective: We conducted a comprehensive assessment of guideline adherence in paediatric asthma care, including inpatient and ambulatory services, in Australia. Methods: National and international clinical practice guidelines (CPG) relating to asthma in children were searched and 39 medical record audit indicator questions were developed. Retrospective medical record review was conducted across hospital inpatient admissions, emergency department (ED) presentations, general practice (GP) and paediatrician consultations in three Australian states for children aged ≤15 years receiving care in 2012 and 2013. Eligibility of, and adherence to, indicators was assessed from medical records by nine experienced and purpose‐trained paediatric nurses (surveyors). Results: Surveyors conducted 18 453 asthma indicator assessments across 1600 visits for 881 children in 129 locations. Overall, the adherence for asthma care across the 39 indicators was 58.1%, with 54.4% adherence at GP (95% CI: 46.0–62.5), 77.7% by paediatricians (95% CI: 40.5–97.0), 79.9% in ED (95% CI: 70.6–87.3) and 85.1% for inpatient care (95% CI: 76.7–91.5). For 14 acute asthma indicators, overall adherence was 56.3% (95% CI: 47.6–64.7). Lowest adherences were for recording all four types of vital signs in children aged >2 years presenting with asthma attack (15.1%, 95% CI: 8.7–23.7), and reviewing patients' compliance, inhaler technique and triggers prior to commencing a new drug therapy (20.5%, 95% CI: 10.1–34.8). Conclusion: The study demonstrated differences between existing care and CPG recommendations for paediatric asthma care in Australia. Evidence‐based interventions to improve adherence to CPG may help to standardize quality of paediatric asthma care and reduce variation of care. [ABSTRACT FROM AUTHOR]

Objectives: To determine the proportion of care provided to children with acute gastroenteritis (AGE) in Australia consistent with clinical practice guidelines. Methods: Indicators were developed from national and international clinical practice guideline (CPG) recommendations and validated by an expert panel. Medical records from children ≤15 years presenting with AGE in three healthcare settings–Emergency Department (ED), hospital admissions and General Practitioner (GP) consultations–from randomly selected health districts across three Australian States were reviewed. Records were audited against 35 indicators by trained paediatric nurses, to determine adherence to CPGs during diagnosis, treatment, and ongoing management. Results: A total of 14,434 indicator assessments were performed from 854 healthcare visits for AGE by 669 children, across 75 GPs, 34 EDs and 26 hospital inpatient services. Documented adherence to guidelines across all healthcare settings was 45.5% for indicators relating to diagnosis (95% CI: 40.7–50.4), 96.1% for treatment (95% CI: 94.8–97.1) and 57.6% for ongoing management (95% CI: 51.3–63.7). Adherence varied by healthcare setting, with adherence in GPs (54.6%; 95% CI: 51.1–58.1) lower than for either ED settings (84.7%; 95% CI: 82.4–86.9) or for inpatients (84.3%; 95% CI: 80.0–87.9); p<0.0001 for both differences. The difference between settings was driven by differences in the diagnosis and ongoing management phases of care. Conclusions: Adherence to clinical guidelines for children presenting to healthcare providers with AGE varies according to phase of care and healthcare setting. Although appropriate diagnostic assessment and ongoing management phase procedures are not well documented in medical records (particularly in the GP setting), in the treatment phase children are treated in accordance with guidelines over 90% of the time. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Variable and poor care quality are important causes of preventable patient harm. Many patients receive less than recommended care, but the extent of the problem remains largely unknown. The CareTrack Kids (CTK) research programme sought to address this evidence gap by developing a set of indicators to measure the quality of care for common paediatric conditions. In this study, we focus on one clinical area, 'preventive care' for pre-school aged children. Our objectives were two-fold: (i) develop and validate preventive care quality indicators and (ii) apply them in general medical practice to measure adherence.Methods: Clinical experts (n = 6) developed indicator questions (IQs) from clinical practice guideline (CPG) recommendations using a multi-stage modified Delphi process, which were pilot tested in general practice. The medical records of Australian children (n = 976) from general practices (n = 80) in Queensland, New South Wales and South Australia identified as having a consultation for one of 17 CTK conditions of interest were retrospectively reviewed by trained paediatric nurses. Statistical analyses were performed to estimate percentage compliance and its 95% confidence intervals.Results: IQs (n = 43) and eight care 'bundles' were developed and validated. Care was delivered in line with the IQs in 43.3% of eligible healthcare encounters (95% CI 30.5-56.7). The bundles of care with the highest compliance were 'immunisation' (80.1%, 95% CI 65.7-90.4), 'anthropometric measurements' (52.7%, 95% CI 35.6-69.4) and 'nutrition assessments' (38.5%, 95% CI 24.3-54.3), and lowest for 'visual assessment' (17.9%, 95% CI 8.2-31.9), 'musculoskeletal examinations' (24.4%, 95% CI 13.1-39.1) and 'cardiovascular examinations' (30.9%, 95% CI 12.3-55.5).Conclusions: This study is the first known attempt to develop specific preventive care quality indicators and measure their delivery to Australian children in general practice. Our findings that preventive care is not reliably delivered to all Australian children and that there is substantial variation in adherence with the IQs provide a starting point for clinicians, researchers and policy makers when considering how the gap between recommended and actual care may be narrowed. The findings may also help inform the development of specific improvement interventions, incentives and national standards. [ABSTRACT FROM AUTHOR]