Variations in Clinical Practice: Assessing Clinical Care Processes According to Clinical Guidelines in a National Cohort of Hospice Patients

Abstract

Background: National clinical guidelines have been developed internationally to reduce variations in clinical practices and promote the quality of palliative care. In The Netherlands, there is considerable variability in the organisation and care processes of inpatient palliative care, with three types of hospices – Volunteer-Driven Hospices (VDH), Stand-Alone Hospices (SAH), and nursing home Hospice Units (HU). Aim: This study aims to examine clinical practices in palliative care through different hospice types and identify variations in care. Methods: Retrospective cohort study utilising clinical documentation review, including patients who received inpatient palliative care at 51 different hospices and died in 2017 or 2018. Care provision for each patient for the management of pain, delirium and palliative sedation were analysed according to the Dutch national guidelines. Results: 412 patients were included: 112 patients who received treatment for pain, 53 for delirium, and 116 patients underwent palliative sedation therapy. Care was provided in accordance with guidelines for pain in 32%, 61% and 47% (P = .047), delirium in 29%, 78% and 79% (P = .0016), and palliative sedation in 35%, 63% and 42% (P = .067) of patients who received care in VDHs, SAHs and HUs respectively. When all clinical practices were considered, patient care was conducted according to the guidelines for 33% of patients in VDHs, 65% in SAHs, and 50% in HUs (P < .001). Conclusions: The data demonstrate that care practices are not standardised throughout Dutch hospices and exhibit significant variations between type of hospice.

A modelling approach to studying variations in newborn life support procedure

“…However, variations in clinical practice results are not only caused by the patient's condition. Local management policy and protocol, [1][2][3] leadership, 4,5 clinical staff bias, [6][7][8] social relationship, 9 interpersonal skill, 10 an availability of clear clinical guidelines, academic background of the clinical staff, 11 and their workload level [12][13][14] are additional examples of factors that may cause the variations. Some of these factors result in a number of unwarranted variations that would cause undesired consequences, such as a longer completion time of a clinical task, failures to deliver effective treatments to patients, and unnecessary cost of healthcare services.…”

“…A higher probability of inflation error means that more failures in the inflation procedure are caused by technical errors during the procedure. In other words, the probability of poor physical condition causing inflation failure is (1) /0.667 (2) 0.421 (1) / 0.781 (2) 0.5135 0.60115 T20 Probability of inflation error given no previous error found 0.359 (1) /0.667 (2) 0.421 (1) / 0.781 (2) 0.5135 0.60115 T20 Probability of inflation error given previous error found in an unsuccessful inflation 0.11 (3) /0.33 (4) 0.22 T22 Probability of considering intubation sufficiency after the first attempt 0.28 (5) /0.52 (6) 0.4…”