The CTK study was a large-scale survey sampling from 60% of Australia’s paediatric population in three states, including 550 medical record reviews for febrile children presenting to GPs and EDs of general or speciality hospitals or admitted as inpatients. The fever study, as a subset of the broader CTK report [7], examined a cohort of children (0–15 years) where care for fever was documented in their clinical record. Adherence was assessed for 47 indicators derived from CPG guidelines and considered by expert panels to be reflective of best practice. As the study was retrospective, it is not possible to determine whether lack of adherence was because the recommended care was not provided by the clinician at the point of care, or simply not documented in the medical record.
It is reassuring that higher adherence seemed to be directly proportional to the degree of risk of serious underlying disease. For example, for infants < 3 months presenting to ED with a fever (FEVE35–37), appropriateness of care relating to investigations was > 90% for all three indicators. Adherence was higher for infants < 3 months than children aged 4–15 years. Others have commented on the high risk of serious bacterial infections in neonates and infants < 3 months, as well as the relative consistency of both guidelines and practice in these age groups compared to older children [1, 15]. One explanation for the lower adherence for children aged 4–15 years may be that as CPGs are focussed on care for children who are under 5 years old or less [10,11,12,13,14], clinicians may be less likely to use them as a guide for older children.
We found higher adherence in inpatient and ED settings than for the GP setting. It is possible that these differences reflect the inherent contextual constraints of the GP setting. Time pressures are likely to affect documentation, particularly during the Assessment phase of care when responses are a result of yes/no questioning, and when a negative result is received. There may also be a degree of assumed risk stratification when children and babies are taken to a GP rather than an ED. GPs may not consider the guidelines as reliable or valid for their practice [16] nor may they be aware of their existence [17] as the three Australian guidelines that were used for this study were released by either Departments of Health (in New South Wales [13] and South Australia [14]) or a children’s hospital [12]. None of these were endorsed by recognised GP organisations.
Clinicians were more often adherent with indicators pertaining to the Diagnostics and Treatment phases of care than for the Assessment phase of care (Fig. 2). Considering documentation as a factor in such differences, it may be more likely to be neglected during assessment when it is not an inherent function of the care process, as distinct from ordering tests or prescribing treatment.
The Assessment phase of care incorporated almost half (n = 21) of all 47 clinical indicators included for the fever condition, a bias supported by the literature [1, 2, 18] where emphasis is placed on gathering as much “hands-off’ information as possible about the febrile child. The average adherence during the Assessment phase of fever care exhibited wide variability in our study, ranging from 14.7 to 90.4%. In contrast, the care provided during the Diagnostics phase of care was uniformly high across the eight reported indicators. Over three-quarters of the care provided to children in this phase of care was adherent, with infants < 3 months faring particularly well (> 90% adherence). The Treatment phase of care also yielded higher adherence though no pattern emerges when analysed by age, however it should be noted that there were insufficient data to assess the appropriateness of many of the treatment decisions for infants and for toxic children in older age groups.
Comparison with other studies
An adherence rate of 51.4% (95% CI: 43.2–59.6) was estimated in the 148 eligible children with fever (< 18 years of age) in a USA ambulatory setting, whose care was assessed for 15 indicators [19]. While the overall adherence rate is similar, results at the indicator level were not always directly comparable. For example, in the US study urine cultures were obtained for 16.2% of children 3 to 36 months of age, whereas over 78% of children in the same age group received urine microscopy in our study. Two further studies of febrile infants attending paediatric EDs in the USA, show wide variation in adherence to recommended management for febrile neonates [20], and poor adherence to current guidelines for diagnostic evaluation, particularly for infants aged 60–90 days [15]. Both studies concluded that further research is required to understand the determinants of variability before strategies can be employed to improve adherence.
Guidelines and rules have been developed but consistency and efficacy could improve
CPGs on the management of fever in children have been developed, assessed and revised over several decades by many expert bodies to better guide practitioners in delivering appropriate care [21]. Yet, definitive conclusions on some aspects of fever management remain contested, particularly for children > 28 days, where recommended investigations and thresholds for antibiotic administration vary considerably [22]. A recent international systematic review of guidelines for the symptomatic management of fever in children identified seven common recommendations and ten discordant recommendations–mostly concerning pharmacological approach–from amongst the seven guidelines evaluated using the Appraisal of Guidelines for Research & Evaluation AGREE II tool [21].
Clinical prediction rules and models have also been developed, to improve diagnostic performance in particular [1]. A recent study, comparing four widely used clinical prediction rules and two national guidelines, found that none had perfect diagnostic accuracy and none were considered valuable in ED settings [23]. This lack of consistency and accuracy in the recommended care of children with fever present real challenges for clinicians aiming to deliver high quality care. A computer-assisted diagnostic decision system developed in Australia [18], integrating 40 clinical variables, shows more promise to improve sensitivity and thus early treatment.
Interventions that improve adherence
Even when clinicians are aware of the evidence and are willing to change practice accordingly, altering well established care processes can be difficult without a thorough ‘due diligence’ phase (assessment of barriers and determinants prior to implementation) and a supportive environment conducive to quality improvement [24,25,26]. A multifaceted, organisationally relevant approach is necessary, with educational outreach, buy-in and support of both clinicians and executives, underpinned by a systemic, real-time capacity to prompt, monitor, evaluate and feedback on practice [27,28,29,30].
Organisational culture is both a determinant and a product of standardisation of care, adherence to available guidelines and quality improvement [24]. When shared purpose, teamwork and enthusiasm to learn and improve dominate organisational culture, the introduction of standardisation and of evidence-based practice finds fertile ground and far fewer obstacles [31,32,33,34,35].
Strengths and weakness of the study
There are strengths and limitations to both the overall CTK study [7] and the fever-specific results reported here. Predictably, few febrile children presented directly to specialist paediatrician’s offices, requiring this setting to be removed prior to analysis. This reflects the referral pathways that are in place in Australia where a GP referral is required before a child can be seen in an ambulatory setting by a specialist paediatrician, subsidised by universal insurance.
While hospitals had excellent participation rates, we estimate that around a quarter of GPs were recruited. Accordingly, the potential impact of self-selection bias cannot be excluded, and it may have led to over-estimating adherence.
There were insufficient data to draw any conclusions about the care of neonates, infants and children in the highest risk categories (in shock, unrousable, toxic or showing signs of meningococcal disease), to come to any conclusions on the appropriateness of care for each of these important sub-cohorts. A larger sample size, or a sampling strategy targeting higher risk children, may have overcome this obstacle.
The study assessed processes of care during a visit without distinguishing between primary and subsequent visits for the same febrile episode. The study is therefore unable to provide information on issues such as the frequency of re-visits which may have resulted from missed diagnosis.
Like other studies on appropriateness of care [36, 37], the CTK study utilised medical record review to assess adherence to best practice. Clinicians may, understandably, be more inclined to document aspects of a history that are abnormal or elicit a result of positive value in elucidating the source of fever. We speculate that this may contribute to the lower levels of adherence in the GP setting as well as for the Assessment phase across all provider types. To partially mitigate this weakness, any indicators that the expert panels perceived to be unlikely to be documented were eliminated from the fever set during indicator selection. It is also possible that the opposite may have occurred, and assessments, investigations or treatments were documented without being carried out.
A strength of the study is that it did not restrict the assessment of appropriateness to just one meritorious guideline on fever. Rather, it aimed to assess best practice by selecting common recommendations from a range of reputable guidelines likely to be used by Australian clinicians. Expert groups then validated their inclusion based on acceptability, feasibility, and impact. A further strength of this study was the inclusion of all age ranges and care settings relevant to febrile illness in children.
