CareTrack Aged: the appropriateness of care delivered to Australians living in residential aged care facilities: a study protocol

Quality indicators to monitor the quality and safety of care for older people: a scoping review protocol

OBJECTIVE

The objective of this review is to identify quality indicators used to monitor the quality and safety of care provided to older people (≥ 65 years old) in 8 care settings: primary care; hospital/acute care; aged care (including residential aged care and home or community care); palliative care; rehabilitation care; care transitions; dementia care; and care in rural areas.

INTRODUCTION

There is a need for high-quality, holistic, person-centered aged and health care for older people. Older people receive care across multiple care settings, and population-level monitoring of quality and safety of care across settings represents a significant challenge.

INCLUSION CRITERIA

National and international quality indicators used to monitor and evaluate quality and safety of care at the population level for older individuals in the 8 key care settings will be considered for inclusion. English-language quantitative and mixed method studies published from 2012 will be considered.

METHODS

Academic (MEDLINE, Embase) and gray (government websites, clinical guidelines, Google) literature searches will be conducted. A standardized data extraction tool will be used to describe the identified quality indicators and associated tools. Quality indicators will be categorized by key domains (ie, pain, function, consumer experience, service delivery), quality indicator type (structure, process, outcome) and the Institute of Medicine's 6 dimensions of care quality (eg, efficiency, effectiveness, appropriateness, accessibility, acceptability/person-centered, safety). The scoping review will be conducted in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

REVIEW REGISTRATION

Open Science Framework osf.io/8czun.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study)

BACKGROUND

This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations.

METHODS

Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators.

RESULTS

Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators.

CONCLUSIONS

This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Designing Clinical Indicators for Common Residential Aged Care Conditions and Processes of Care: The CareTrack Aged Development and Validation Study

BACKGROUND

People who live in aged care homes have high rates of illness and frailty. Providing evidence-based care to this population is vital to ensure the highest possible quality of life. This study (CareTrack Aged, CT Aged) aimed to develop a comprehensive set of clinical indicators for guideline-adherent, appropriate care of commonly managed conditions and processes of care in aged care.

METHODS

Indicators were formulated from recommendations found through systematic searches of Australian and international clinical practice guidelines (CPGs). Experts reviewed the indicators using a multi-round modified Delphi process to develop consensus on what constitutes appropriate care.

RESULTS

From 139 CPGs, 5,609 recommendations were used to draft 630 indicators. Clinical experts (n=41) reviewed the indicators over two rounds. A final set of 236 indicators resulted, mapped to 16 conditions and processes of care. The conditions and processes were admission assessment; bladder and bowel problems; cognitive impairment; depression; dysphagia and aspiration; end of life/palliative care; hearing and vision; infection; medication; mobility and falls; nutrition and hydration; oral and dental care; pain; restraint use; skin integrity; and sleep.

CONCLUSIONS

The suite of CT Aged clinical indicators can be used for research, assessment of quality of care in individual facilities and across organisations to guide improvement, and to supplement regulation or accreditation of the aged care sector. They are a step forward for Australian and international aged care sectors, helping to improve transparency, so that the level of care delivered to aged care consumers can be rigorously monitored and continuously improved.

Exploring the actionability of healthcare performance indicators for quality of care: a qualitative analysis of the literature, expert opinion and user experience

BACKGROUND

This study explores the meaning of actionable healthcare performance indicators for quality of care-related decisions. To do so, we analyse the constructs of fitness for purpose and fitness for use across healthcare systems and in practice based on the literature, expert opinion and user experience.

METHODS

A multiphase qualitative study was undertaken. Phases included a literature review, a first round of one-on-one interviews with a panel of academics and thought leaders in the field (n=16), and a second round of interviews with real-world users of performance indicators (n=16). Thematic analysis was conducted between phases in order to triangulate findings in a stepwise process.

RESULTS

Common uses of healthcare performance indicators were differentiated within micro-meso-macro contexts of healthcare systems. Each purpose of use signals different decision-making tasks, and in effect information needs. An indicator's fitness for use can be appraised by three clusters of considerations: methodological, contextual and managerial. Methodological considerations gauge an indicator's perceived importance, engagement potential, interpretability, standardisation, feasibility of remedial actions, alignment to care models and sensitivity to change. Information infrastructure, system governance, workforce capacity and learning culture were found as enabling contextual considerations. Managerial considerations influencing an indicator's use in practice were found to span the selection of indicators, data collection, analysis, display of results and delivery of information to decision-makers.

CONCLUSION

The actionability of a healthcare performance indicator should be appraised by its alignment with the intended purpose of use beyond aggregate healthcare system levels, in combination with the extent to which methodological, contextual and managerial fitness for use considerations are met. Striking a better balance between the importance weighted to an indicator's statistical merits and emphasis put to its fitness for purpose and use is needed for indicators that are ultimately actionable for quality of care-related decision-making.

Incidence of adverse incidents in residential aged care

ObjectiveAdverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs.MethodsA concurrent mixed-methods design was used to examine 3 years of incident management report data from 72 RACFs in New South Wales and the Australian Capital Territory. Qualitative thematic analysis of free-text incident descriptions was undertaken to group adverse incidents into categories. The rates and types of adverse incidents based on these categories were calculated and then compared using incidence rate ratios (IRRs).ResultsDeidentified records of 11 987 permanent residents (aged ≥65 years; mean (±s.d.) age 84 ± 8 years) from the facilities were included. Of the 60 268 adverse incidents, falls were the most common event (36%), followed by behaviour-related events (33%), other impacts and injuries (22%) and medication errors (9%). The number of adverse incidents per resident ranged from 0 (42%) to 171, with a median of 2. Women (IRR 0.804; P < 0.001) and residents with low care needs (IRR 0.652; P < 0.001) were significantly less likely to adverse incidents compared with men and residents with high care needs respectively.ConclusionThis study demonstrates that data already collected within electronic management systems can provide crucial baseline information about the risk levels that adverse incidents pose to older Australians living in RACFs.What is known about the topic?To date, research into aged care adverse incidents has typically focused on single incident types in small studies involving mitigation strategies. Little has been published quantifying the multiple adverse incidents experienced by residents of aged care facilities or reporting organisation-wide rates of adverse incidents.What does this paper add?This paper adds to the growing breadth of Australian aged care research by providing baseline information on the rates and types of adverse incidents in RACFs across a large and representative provider.What are the implications for practitioners?This research demonstrates that the wealth of data captured by aged care facilities' incident management information systems can be used to provide insight into areas of commonly occurring adverse incidents. Better use of this information could greatly enhance strategic planning of quality improvement activities and the care provided to residents.