Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

Sutherland, Kim; Lévesque, Jean‐Frédéric

doi:10.1111/jep.13181

Cited by 97 publications

(122 citation statements)

References 40 publications

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“…Findings from this study support the results of earlier research, suggesting incongruences in hand hygiene practices before and after patient care (Ding et al, ). Yet, in comparing practice variations across contexts, it is important to separate contextual factors that are outside the direct control at that level and those that are amenable to change (Sutherland & Levesque, ). Clearly, inconsistencies in practices may be due to environmental factors outside of the control of healthcare providers, viz, time constraints, skill mix, workload and patient acuity.…”

Section: Discussionmentioning

confidence: 99%

“…It is often accepted that wound care practices are influenced by various local factors, and not just the evidence. For instance, the resources available, skill mix, clinician preferences, patient behaviour and length of hospital stay contribute to practice variation (Sutherland & Levesque, ). A systematic review of medical practice variation in developed countries identified 836 published studies and detailed variation across regions, hospitals and physician practices in almost every surgical field, condition and procedure (Corallo et al, ).…”

Section: Introductionmentioning

confidence: 99%

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Wound care practices across two acute care settings: A comparative study

Gillespie

Walker

Lin

et al. 2019

Journal of Clinical Nursing

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Aims and objectives Describe and compare current surgical wound care practices across two hospitals in two health services districts, Australia. Background Surgical site infections (SSI) are a complication of surgery and occur in up to 9.5% of surgical procedures, yet they are preventable. Despite the existence of clinical guidelines for SSI prevention, there remains high variation in wound care practice. Design Prospective comparative design using structured observations and chart audit. Methods A specifically developed audit tool was used to collect data on observed wound care practices, documentation of wound assessment and practice, and patients’ clinical characteristics from patients’ electronic medical records. Structured observations of a consecutive sample of surgical patients receiving wound care with a convenience sample of nurses were undertaken. The manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Results In total, 154 nurses undertaking acute wound care and 257 surgical patients who received wound care were observed. Across hospitals, hand hygiene adherence after dressing change was lowest (Hospital A: 8/113, 7%; Hospital B: 16/144, 11%; χ2: 8.93, p = .347). Most wound dressing practices were similar across sites, except hand hygiene prior to dressing change (Hospital A: 107/113, 95%; Hospital B: 131/144, 91%; (χ2: 7.736, p = .021) and use of clean gloves using nontouch technique (Hospital A: 88/113, 78%; Hospital B: 90/144, 63%; χ2: 8.313, p = .016). The most commonly documented wound characteristic was wound type (Hospital A: 43/113, 38%; Hospital B: 70/144, 49%). What nurses documented differed significantly across sites (p < .05). Conclusions Clinical variations in wound care practice are likely influenced by clinical context. Relevance to clinical practice Using an evidence‐based approach to surgical wound management will help reduce patients’ risk of wound‐related complications.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Wound care practices across two acute care settings: A comparative study

Gillespie

Walker

Lin

et al. 2019

Journal of Clinical Nursing

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“…Countries including the United States of America (USA), Canada, Spain, United Kingdom (UK), Germany, the Netherlands, Norway, New Zealand and Australia have produced atlases of variation in health care to guide system and service improvements [4][5][6]. Through these atlases, substantial variations in the healthcare provided to patients have been identified across each country, with implications for patient outcomes [7]. Variations have been reported in a range of care areas including surgery for hysterectomy, cataract surgery, planned Caesarian section, arthroscopic surgery and potentially preventable hospitalisations for selected conditions [8,9].…”

Section: Introductionmentioning

confidence: 99%

“…Unwarranted clinical variation (UCV) describes "patient care that differs in ways that are not a direct and proportionate response to available evidence; or to the healthcare needs and informed choices of patients." [7] Understanding variation and what is unwarranted has been identified as important in guiding valuebased healthcare [8,11]. Value-based healthcare has been conceptualised in the US context in terms of the 'health outcome achieved per dollar spent,' but more recently in the UK in terms of optimising the value of resources through their utilisation for each patient sub-group, which is determined by clinicians [12,13].…”

Section: Introductionmentioning

confidence: 99%

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Harrison

Hinchcliff

Manias

et al. 2020

BMC Health Serv Res

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Background Assessment of clinical variation has attracted increasing interest in health systems internationally due to growing awareness about better value and appropriate health care as a mechanism for enhancing efficient, effective and timely care. Feedback using administrative databases to provide benchmarking data has been utilised in several countries to explore clinical care variation and to enhance guideline adherent care. Whilst methods for detecting variation are well-established, methods for determining variation that is unwarranted and addressing this are strongly debated. This study aimed to synthesize published evidence of the use of feedback approaches to address unwarranted clinical variation (UCV). Methods A rapid review and narrative evidence synthesis was undertaken as a policy-focused review to understand how feedback approaches have been applied to address UCV specifically. Key words, synonyms and subject headings were used to search the major electronic databases Medline and PubMed between 2000 and 2018. Titles and abstracts of publications were screened by two reviewers and independently checked by a third reviewer. Full text articles were screened against the eligibility criteria. Key findings were extracted and integrated in a narrative synthesis. Results Feedback approaches that occurred over a duration of 1 month to 9 years to address clinical variation emerged from 27 publications with quantitative (20), theoretical/conceptual/descriptive work (4) and mixed or multi-method studies (3). Approaches ranged from presenting evidence to individuals, teams and organisations, to providing facilitated tailored feedback supported by a process of ongoing dialogue to enable change. Feedback approaches identified primarily focused on changing clinician decision-making and behaviour. Providing feedback to clinicians was identified, in a range of a settings, as associated with changes in variation such as reducing overuse of tests and treatments, reducing variations in optimal patient clinical outcomes and increasing guideline or protocol adherence. Conclusions The review findings suggest value in the use of feedback approaches to respond to clinical variation and understand when action is warranted. Evaluation of the effectiveness of particular feedback approaches is now required to determine if there is an optimal approach to create change where needed.

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“…Medical practice variation is unwarranted if it cannot be explained by patient characteristics or patient preference [9,10]. To identify unwarranted practice variation, studies should compare study groups that are comparable in terms of relevant patient characteristics or make them comparable through careful case-mix correction [11]. Patient preference is important when both modes of deliveryvaginal delivery and caesarean sectionare an acceptable option.…”

Section: Introductionmentioning

confidence: 99%

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

Vink

Bekker

Koolman

et al. 2020

BMC Pregnancy Childbirth

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Background: Medical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback. Methods: We searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics). Results: A total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%. Conclusions: Study designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

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Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

Cited by 97 publications

References 40 publications

Wound care practices across two acute care settings: A comparative study

Wound care practices across two acute care settings: A comparative study

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

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