A systematic review of medical practice variation in OECD countries

A Framework for Understanding How Variation in Health Care Service Delivery Affects Work Disability Management

Introduction Differences in disability duration after work injury have been observed across jurisdictions, regions and urban and rural settings. A key aspect of effective disability management is the access and utilization of appropriate and high quality health care. This paper presents a framework for analyzing and thus understanding how health service spending and utilization vary across and within work disability management schemes and affect work disability management. Methods Our framework was developed through a literature review and policy analysis. Existing frameworks describing geographic variation in general health care systems identified factors believed to drive that variation. A review of policy and practice documents from Canada's no-fault cause-based work disability management system identified factors relevant to work disability systems. Results We expand on previous frameworks by taking a systems approach that centers on factors relevant to the work disability management system. We further highlight predisposing, enabling, workplace environment and need-based factors that could lead to variation in health care spending and utilization across and within jurisdictions. These factors are described as shaping the interactions between workers, health care providers, employers and work disability management system actors, and influencing work disability management health and employment outcomes. Conclusion Our systems-focused approach offers a guide for researchers and policymakers to analyze how various factors may influence spending and utilization across regions and to identify areas for improvement in health care delivery within work disability management systems. Next steps include testing the framework in an analysis looking at geographic variation in spending and utilization across and within Canadian work disability management systems.

Intercountry comparisons of advanced Parkinson's disease symptoms and management: Analysis from the OBSERVE-PD observational study

Objectives

In the absence of widely accepted criteria, determining when a patient with Parkinson's disease (PD) may benefit from more advanced treatments such as device‐aided therapy (DAT) so far remains a matter of physician judgment. This analysis investigates how classification of PD varies across countries relative to measures of disease severity.

Materials and Methods

The OBSERVational, cross‐sEctional PD (OBSERVE‐PD) study included consecutive patients with PD at centers that offer DATs in 18 countries. In this subgroup analysis, we explore intercountry differences in identification of advanced versus non‐advanced PD based on physician's clinical judgment, symptoms assessed using Delphi consensus criteria, use of DAT, motor and non‐motor symptoms, and caregiver support. Demographic and clinical characteristics were obtained through review of medical records.

Results

Overall, 1342 of 2615 patients (51.3%) were assessed by physicians as having advanced PD. The proportion of patients in different countries identified as having advanced PD (24.4–82.2%) varied. In 15 of 18 countries, a greater proportion of patients with advanced PD, according to select Delphi criteria, were identified by physicians as having advanced PD than with non‐advanced PD. There was a wide variability across countries in the proportion of patients with no dyskinesia, disabling dyskinesia, dyskinesia pain, and non‐motor symptoms who were identified by physicians as having advanced versus non‐advanced PD.

Conclusions

The proportion of patients identified with advanced PD symptoms varies widely across countries, despite differences on the patients' profiles, indicating a need for objective diagnostic criteria to help identify patients who may benefit from DAT.

Mind the gap: Mapping variation between national and local clinical practice guidelines for acute paediatric asthma from the United Kingdom and the Netherlands

BACKGROUND

Clinical practice guidelines (CPGs) aim to standardize clinical care. Increasingly, hospitals rely on locally produced guidelines alongside national guidance. This study examines variation between national and local CPGs, using the example of acute paediatric asthma guidance from the United Kingdom and the Netherlands.

METHODS

Fifteen British and Dutch local CPGs were collected with the matching national guidance for the management of acute asthma in children under 18 years old. The drug sequences, routes and methods of administration recommended for patients with severe asthma and the tone of recommendation across both types of CPGs were schematically represented. Deviations from national guidance were measured. Variation in recommended doses of intravenous salbutamol was examined. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II.

RESULTS

British and Dutch national CPGs differed in the recommended drug choices, sequences, routes and methods of administration for severe asthma. Dutch national guidance was more rigidly defined. Local British CPGs diverged from national guidance for 23% of their recommended interventions compared to 8% for Dutch local CPGs. Five British local guidelines and two Dutch local guidelines differed from national guidance for multiple treatment steps. Variation in second-line recommendations was greater than for first-line recommendations across local CPGs from both countries. Recommended starting doses for salbutamol infusions varied by more than tenfold. The quality of the sampled local CPGs was low across all AGREE II domains.

CONCLUSIONS

Local CPGs for the management of severe acute paediatric asthma featured substantial variation and frequently diverged from national guidance. Although limited to one condition, this study suggests that unmeasured variation across local CPGs may contribute to variation of care more broadly, with possible effects on healthcare quality.

Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis

OBJECTIVE

The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance.

METHODS

This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques. Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations.

RESULTS

Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases ('threshold modifiers') which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult.

CONCLUSIONS

This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency - especially where evidence is uncertain, variable or lacking.

A comprehensive model for measuring real-life cost-effectiveness in eyecare: automation in care and evaluation of system (aces-rwm™)

This paper describes a holistic, yet simple and comprehensible, ecosystem model to deal with multiple and complex challenges in eyecare. It aims at producing the best possible wellbeing and eyesight with the available resources. When targeting to improve the real-world cost-effectiveness, what gets done in everyday practice needs be measured routinely, efficiently and unselectively. Collection of all real-world data of all patients will enable evaluation and comparison of eyecare systems and departments between themselves nationally and internationally. The concept advocates a strategy to optimize real-life effectiveness, sustainability and outcomes of the service delivery in ophthalmology. The model consists of three components: (1) resource-governing principles (i.e., to deal with increasing demand and limited resources), (2) real-world monitoring (i.e., to collect structured real-world data utilizing automation and visualization of clinical parameters, health-related quality of life and costs), and (3) digital innovation strategy (i.e., to evaluate and benchmark real-world outcomes and cost-effectiveness). The core value and strength of the model lies in the consensus and collaboration of all Finnish university eye clinics to collect and evaluate the uniformly structured real-world outcomes data. In addition to ophthalmology, the approach is adaptable to any medical discipline to efficiently generate real-world insights and resilience in health systems.

Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates.

ETHICS AND DISSEMINATION

No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021257490.

Unwarranted geographic variation in paediatric health care in the United States and Norway

AIM

We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care.

METHODS

The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate.

RESULTS

The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher.

CONCLUSION

Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Hospital Length of Stay and Related Factors for COVID-19 Inpatients Among the Four Southern Regions Under the Proposed Southern Business Unit of Saudi Arabia

Objective

To assess the length of stay (LoS) variation for COVID-19 inpatients among the four regions of the Southern Business Unit (SBU).

Methods

This is a comparative retrospective study of the LoS of COVID-19 inpatients in the four regions of the SBU in the KSA. Data was collected from the Ministry of Health (MoH) in all hospitals in the SBU. Participants were all patients admitted with confirmed COVID-19 between March 2020 and February 2021. Variables included region (variable of interest), demographics, comorbidities, and complications. Multilinear regression was performed to control for any factors that might have had an association with LoS.

Results

The mean LoS of the total sample was 10 days and Bisha (the reference) was 7 days. Compared to Bisha, LoS in Jazan was 34% longer, in Najran 62% longer, and Aseer 40% longer. We observed that other factors also had an association with LoS, compared to Bisha, compared to the references, Saudi patients had a 15% shorter stay; admission to ICU increased LoS by 57%; patients who died during hospitalization had a 39% shorter LoS; the complications from COVID-19 of acute kidney injury and ARDS increased LoS by 22% and 48% respectively.

Conclusion

After statistically controlling for confounders, this study reveals that LoS was significantly impacted by region in the SBU in the KSA. We recommend that further study be conducted to illuminate the underlying causes of this variation which may be organizational or structural to ensure high quality of care, access to care, and equity of resources throughout all regions of the SBU in accordance with the new Model of Care in Vision 2030.

Learning in Temporary Teams: The Varying Effects of Partner Exposure by Team Member Role

In many workplaces, temporary teams convene to coordinate complex work, despite team members having not worked together before. Most related research has found consistent performance benefits when members of temporary teams work together multiple times (team familiarity). Recent work in this area broke new conceptual ground by instead exploring the learning and performance benefits that team members gain by being exposed to many new partners (partner exposure). In contrast to that new work that examined partner exposure between team members who are peers, in this paper, we extend this research by developing and testing theory about the performance effects of partner exposure for team members whose roles are differentiated by authority and skill. We use visit-level data from a hospital emergency department and leverage the ad hoc assignment of attendings, nurses, and residents to teams and the round-robin assignment of patients to these teams as our identification strategy. We find a negative performance effect of both nurses’ and resident trainees’ partner exposure to more attendings and of attendings’ and nurses’ exposure to more residents. In contrast, both attendings and residents experience a positive impact on performance from working with more nurses. The respective effects of residents working with more attendings and with more nurses is attenuated on patient cases with more structured workflows. Our results suggest that interactions with team members in decision-executing roles, as opposed to decision-initiating roles, is an important but often unrecognized part of disciplinary training and team learning.

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project

BACKGROUND

The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years.

METHODS

This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented.

RESULTS

A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest.

CONCLUSIONS

We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

Small Area Variation of Adherence to Clinical Recommendations: An Example from Switzerland

Background

Unwarranted variation in healthcare utilization can only partly be explained by variation in the health care needs of the population, yet it is frequently found globally. This is the first cross-sectional study that systematically assessed geographic variation in the adherence to clinical recommendations in Switzerland. Specifically, we explored 1) the geographic variation of adherence to clinical recommendations across 24 health services at the sub-cantonal level, 2) assessed and mapped statistically significant spatial clusters, and 3) explored possible influencing factors for the observed geographic variation.

Methods

Exploratory spatial analysis using the Moran's I statistic on multivariable multilevel model residuals to systematically identify small area variation of adherence to clinical recommendations across 24 health services.

Results

Although there was no overall spatial pattern in adherence to clinical recommendations across all health care services, we identified health services that exhibited statistically significant spatial dependence in adherence. For these, we provided evidence about the locations of local clusters.

Interpretation

We identified regions in Switzerland in which specific recommended or discouraged health care services are utilized less or more than elsewhere. Future studies are needed to investigate the place-based social determinants of health responsible for the sub-cantonal variation in adherence to clinical recommendations in Switzerland and elsewhere over time.

Variability drivers of treatment costs in hospitals: A systematic review

OBJECTIVES

Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020.

RESULTS

90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors.

CONCLUSION

Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

Prospective Interventions to Reduce Stroke Care Variation in a Hub-and-Spokes System

BACKGROUND

Care variation reduction (CVR) is a central objective of quality management to decrease wasted spending.

OBJECTIVE

To analyze stroke care variation at a hub-and-spokes system and determine interventions to prospectively reduce unwarranted variation.

METHODS

In this prospective cohort single arm intervention study providers were blinded to pre-specified endpoints. Care variation was measured for DRGs 61-66 and 69 in USD, and severity level by Case Mix Index (CMI) by provider. A multi-disciplinary task force chaired by Vascular Neurologist analyzed data extracted from Crimson, a patient centric data analysis tool, and determined interventions. The primary measure outcome was change in CMI post intervention.

RESULTS

Annualized baseline care variation was $ 0.7-1.2M (2017) in a drip-and-ship thrombolytic treatment model within the hub-and-spokes system. Pharmacy expenses contributed to 42% of variation followed by laboratory 12%, physical therapy 11%, supplies 11% and imaging 9%. Interventions to achieve CVR were prospectively implemented in 2018 and CVR was measured in January 2019. Based on 2017 CMI of 1.28, the goal of intervention was set to achieve 7% increase to 1.37 with projected increased revenue of $774,144. After implementation of interventions the actual achieved average CMI in 2018 was 1.40 paralleled by improvement in secondary outcomes of length of stay, observed over expected mortality and re-admission.

CONCLUSIONS

A drip-and-ship stroke model within a single hub-and-spokes healthcare system can achieve substantial reduction in care variation and associated cost along with improvement in patient care indicators.

Variation in chemotherapy prescribing rates and mortality in early breast cancer over two decades: a national data linkage study

Background

Regional variation in clinical practice may identify differences in care, reveal inequity in access, and explain inequality in outcomes. The study aim was to measure geographical variation in Scotland for adjuvant chemotherapy use and mortality in early-stage breast cancer.

Patients and methods

In this retrospective cohort study using population cancer registry-based data linkage, patients with surgically treated early breast cancer between 2001 and 2018 were identified from the Scottish Cancer Registry. Geographical regions considered were based on NHS Scotland organisational structure including 14 territorial Health Boards as well as three regional Cancer Networks. Regional variation in the proportion receiving chemotherapy, breast cancer mortality and all-cause mortality was investigated. Inter-regional comparisons of chemotherapy use were adjusted for differences in case mix using logistic regression. Comparison of breast cancer-specific mortality and all-cause mortality used regression with a parametric survival model. Time trends were assessed using moving average plots.

Results

Chemotherapy use ranged from 35% to 46% of patients across Health Boards without adjustment. Variation reduced between 2001 and 2018. Following adjustment for clinical case mix, variation between cancer networks was within 3 percentage points, but up to 10 percentage points from the national average in some Health Boards. Differences in breast cancer mortality and all-cause mortality between cancer networks were modest, with hazard ratios of between 0.933 (95% confidence interval 0.893-0.975) and 1.041 (1.002-1.082) compared with the national average. Survival improved over the time period studied.

Conclusion

With adequate case mix adjustment, variation in adjuvant chemotherapy use for early breast cancer in Scotland is small, with a trend towards greater convergence in practice and improved mortality outcomes in more recent cohorts. This suggests very limited regional inequity in access and convergence of clinical practice towards risk-stratified treatment recommendations. Outliers require assessment to understand the reasons for variance.

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A cohort study including the Scottish population of surgically treated early breast cancer patients from 2001 to 2018.

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With adequate case mix adjustment, regional variation in adjuvant chemotherapy use was small, but with notable outliers.

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Over time there was a trend towards greater convergence in practice towards risk-stratified treatment recommendations.

Within and across country variations in treatment of patients with heart failure and diabetes

OBJECTIVE

To compare within-country variation of health care utilization and spending of patients with chronic heart failure (CHF) and diabetes across countries.

DATA SOURCES

Patient-level linked data sources compiled by the International Collaborative on Costs, Outcomes, and Needs in Care across nine countries: Australia, Canada, England, France, Germany, New Zealand, Spain, Switzerland, and the United States.

DATA COLLECTION METHODS

Patients were identified in routine hospital data with a primary diagnosis of CHF and a secondary diagnosis of diabetes in 2015/2016.

STUDY DESIGN

We calculated the care consumption of patients after a hospital admission over a year across the care pathway-ranging from primary care to home health nursing care. To compare the distribution of care consumption in each country, we use Gini coefficients, Lorenz curves, and female-male ratios for eight utilization and spending measures.

PRINCIPAL FINDINGS

In all countries, rehabilitation and home nursing care were highly concentrated in the top decile of patients, while the number of drug prescriptions were more uniformly distributed. On average, the Gini coefficient for drug consumption is about 0.30 (95% confidence interval (CI): 0.27-0.36), while it is, 0.50 (0.45-0.56) for primary care visits, and more than 0.75 (0.81-0.92) for rehabilitation use and nurse visits at home (0.78; 0.62-0.9). Variations in spending were more pronounced than in utilization. Compared to men, women spend more days at initial hospital admission (+5%, 1.01-1.06), have a higher number of prescriptions (+7%, 1.05-1.09), and substantially more rehabilitation and home care (+20% to 35%, 0.79-1.6, 0.99-1.64), but have fewer visits to specialists (-10%; 0.84-0.97).

CONCLUSIONS

Distribution of health care consumption in different settings varies within countries, but there are also some common treatment patterns across all countries. Clinicians and policy makers need to look into these differences in care utilization by sex and care setting to determine whether they are justified or indicate suboptimal care.

Regional Differences in COVID-19 Mortality Rates in the Kingdom of Saudi Arabia: A Simulation of the New Model of Care

Background This study aimed to assess regional COVID-19 mortality rates and compare the five proposed business units (BUs).  Methods A cross-sectional study was conducted in the Ministry of Health (MOH) hospitals in the Kingdom of Saudi Arabia (KSA). We included 1743 adults (≥ 18 years of age) with COVID-19 admitted to any of 30 MOH hospitals. Results The inpatients had confirmed mild to severe COVID-19 between March and mid-July 2020. The central BU (Riyadh) was used as the reference. MOH electronic health record data were reviewed and utilized, including variables reflecting hospital course (mortality and discharge status). The primary outcome was COVID-19-related inpatient death. Covariates included patient demographics, pre-existing chronic diseases, and COVID-19-related complications. The data were analysed using univariate and multivariate logistic regression. KSA inpatient mortality was 30%. Univariate and multivariate logistic regression analysis suggested that COVID-19-related mortality was significantly higher in the northern and western BUs and significantly lower in the southern and eastern BUs than in the central BU. On controlling for other variables, adjusted odds ratios (AORs) for essential COVID-19 mortality predictors during admission, using the central BU as a reference, were as 9.90 [95% CI, 4.53-21.61] and 1.55 [95% CI, 1.04-2.13] times higher in the northern and western BUs, respectively, and 0.60 [95% CI, 0.36-0.99] and 0.23 [95% CI, 0.14-0.038] times lower in the southern and eastern BUs, respectively. Conclusion The five BUs differed in COVID-19 mortality rates after adjusting for patient and disease characteristics, with the differences consistent with those in the regions comprising the BUs. These outcome differences apparently relate to differences in healthcare resources and quality.

Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study

BACKGROUND

Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients.

METHODS

After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated.

RESULTS

Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35).

CONCLUSIONS

Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.

Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease

The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.

Variation in end-of-life care and hospital palliative care among hospitals and local authorities: A preliminary contribution of big data

BACKGROUND

Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use of palliative care.

AIM

Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France.

DESIGN

Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database.

RESULTS

55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84-2.43) and aOR = 2.59 (2.12-3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels.

CONCLUSION

The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.

Motivation to move fast, motivation to wait and see: The association of prevention and promotion focus with clinicians' implementation of the JNC-7 hypertension treatment guidelines

Roughly half of the adults in the United States are diagnosed with hypertension (HTN). Unfortunately, less than one-third have their condition under control. Clinicians generally have positive regard for the use of HTN guidelines to achieve HTN treatment goals; however, actual uptake remains low. Factors underpinning clinician variation in practice are poorly understood. To understand the relationship between clinicians' personal motivation to complete goals and their uptake of the Joint National Commission's HTN guidelines. The authors used Regulatory Focus Theory (RFT, ie, prevention and promotion focus), an empirically supported motivational theory, as a guiding framework to examine the relationship. The authors hypothesized that clinicians with high prevention focus would report following guidelines more often and have shorter follow-up visit intervals for patients with uncontrolled blood pressure. Clinicians (n  = 27) caring for adult patients diagnosed with HTN (n = 8605) in Federally Qualified Health Centers (n = 8). Clinicians' prevention and promotion focus scores and the number of days between visits for their patients with uncontrolled systolic blood pressure (SBP) (≥ 140 mm Hg). Consistent with RFT, 60% of prevention focused clinicians reported they always followed the monthly visit guideline for the patients with uncontrolled blood pressure, compared with 38% of promotion focused clinicians (p = .254). The unadjusted probability of returning for a follow-up visit within 30 days was greater among patients whose clinician was higher in prevention focus (p = .009), but there was no evidence at the 0.05 significance level in our adjusted model. These findings provide some limited evidence that RFT is a useful framework to understand clinician adherence to HTN treatment guidelines.

Conversion of a colorectal cancer guideline into clinical decision trees with assessment of validity

Objective

The interpretation and clinical application of guidelines can be challenging and time-consuming, which may result in noncompliance to guidelines. The aim of this study was to convert the Dutch guideline for colorectal cancer (CRC) into decision trees and subsequently implement decision trees in an online decision support environment to facilitate guideline application.

Methods

The recommendations of the Dutch CRC guidelines (published in 2014) were translated into decision trees consisting of decision nodes, branches and leaves that represent data items, data item values and recommendations, respectively. Decision trees were discussed with experts in the field and published as interactive open access decision support software (available at www.oncoguide.nl). Decision tree validation and a concordance analysis were performed using consecutive reports (January 2016–January 2017) from CRC multidisciplinary tumour boards (MTBs) at Amsterdam University Medical Centers, location AMC.

Results

In total, we developed 34 decision trees driven by 101 decision nodes based on the guideline recommendations. Decision trees represented recommendations for diagnostics (n = 1), staging (n = 10), primary treatment (colon: n = 1, rectum: n = 5, colorectal: n = 9), pathology (n = 4) and follow-up (n = 3) and included one overview decision tree for optimal navigation. We identified several guideline information gaps and areas of inconclusive evidence. A total of 158 patients’ MTB reports were eligible for decision tree validation and resulted in treatment recommendations in 80% of cases. The concordance rate between decision tree treatment recommendations and MTB advices was 81%. Decision trees reported in 22 out of 24 non-concordant cases (92%) that no guideline recommendation was available.

Conclusions

We successfully converted the Dutch CRC guideline into decision trees and identified several information gaps and areas of inconclusive evidence, the latter being the main cause of the observed disagreement between decision tree recommendations and MTB advices. Decision trees may contribute to future strategies to optimize quality of care for CRC patients.

Variations in length of stay of inpatients with COVID-19: A nationwide test of the new model of care under vision 2030 in Saudi Arabia

Objective

The coronavirus disease 2019 (COVID-19) has impacted the Kingdom of Saudi Arabia (KSA) as it has other nations. However, length of stay (LOS), as a healthcare quality indicator, has not been examined across the healthcare regions in the KSA. Therefore, this study aimed to examine factors associated with LOS to better understand the Saudi Health System's performance in response to the COVID-19 pandemic in the newly suggested five Saudi regional business units (BUs).

Methods

A retrospective study was conducted using Ministry of Health (MOH) data on hospital LOS during the period from March to mid-July 2020. Participants were adult inpatients (18 years or older) with confirmed COVID-19 (n = 1743 patients). The 13 regions of the KSA were united into the defined five regional BUs during the reorganization of the health system. Covariates included demographics such as age and sex, comorbidities, and complications of COVID-19. A multiple linear regression with stepwise forward selection was used to model LOS for other explanatory variables associated with LOS, including demographic, comorbidities, and complications.

Results

The mean LOS was 11.85 days which differed significantly across the BUs, ranging from 9.3 days to 13.3 days (p value < 0.001). BUs differed significantly in LOS for transferred patients but not for patients in the intensive care unit (ICU) or those who died in-hospital. The multiple regression analysis revealed that the LOS for inpatients admitted in the Eastern and Southern BUs was significantly shorter than for those in the Central BU. (p value < 0.001). Admission to the ICU was associated with lengthier stays (p value < 0.0001). Factors significantly associated with shorter stays (compared to the reference), were being Saudi, death during admission, and patients referred to another hospital (p value < 0.05).

Conclusion

The LOS for patients with COVID-19 differed across the proposed regional healthcare BUs, suggesting regional differences in quality of care under the reorganization of the national health system. Since patient and disease characteristics did not explain these findings, differences in staffing and other resources need to be examined to develop interventions.

Change in medical practice over time? A register based study of regional trends in hysterectomy in Finland in 2001-2018

Background

A persistent research finding in Finland and elsewhere has been variation in medical practices both between and within countries. Variation seems to exist especially if medical decision making involves discretion and the best treatment cannot be identified unambiguously. This is true for hysterectomy when performed for benign causes. The aim of the current study was to investigate regional trends in hysterectomy in Finland and the potential convergence of rates over time.

Methods

We used hospital discharge register data on hysterectomies performed, diagnoses, age, and region of residence to examine hospital discharges for women undergoing hysterectomy in 2001–2018 among total female population aged 25 years or older in Finland. We examined hysterectomy rates among biannual cohorts by indication, calculated age-standardised rates and used multilevel models to analyse potential convergence over time.

Results

Altogether 131,695 hysterectomies were performed in Finland 2001–2018. We found a decreasing trend, with the age-adjusted overall hysterectomy rate decreasing from 553/100,000 person years in 2001–2002 to 289/100,000 py in 2017–2018. Large but converging regional differences were found. The correlations between hospital district intercepts and slopes in time ranged from − 0.71 to − 0.97 (p < 0.001) suggesting diminishing variation.

Conclusions

Our findings demonstrate that change in hysterectomy practices and more uniformity across regions are achievable goals. Regional variation still exists suggesting differences in medical practices.

Improving Management of Type 2 Diabetes Using Home-Based Telemonitoring: Cohort Study

Background

Diabetes is present in 10.5% of the US population and accounts for 14.3% of all office-based physician visits made by adults. Despite this established office-based approach, the disease and its adverse outcomes including glycemic control and clinical events tend to worsen over time. Available home technology now provides accurate, reliable data that can be transmitted directly to the electronic medical record.

Objective

This study aims to evaluate the impact of a virtual, home-based diabetes management program on clinical measures of diabetes control compared to usual care.

Methods

We evaluated glycemic control and other diabetes-related measures after 1 year in 763 patients with type 2 diabetes enrolled into a home-based digital medicine diabetes program and compared them to 794 patients matched for age, sex, race, BMI, hemoglobin A_1c (HbA_1c), creatinine, estimated glomerular filtration rate, and insulin use in a usual care group after 1 year. Digital medicine patients completed questionnaires online, received medication management and lifestyle recommendations from a clinical pharmacist or advanced practice provider and a health coach, and were asked to submit blood glucose readings using a commercially available Bluetooth-enabled glucose meter that transmitted data directly to the electronic medical record.

Results

After 1 year, usual care patients demonstrated no significant changes in HbA_1c (mean 7.3, SE 1.7 to mean 7.3, SE 1.6; P=.41) or changes in the proportion of patients with HbA_1c≥9.0 (n=117, 15% to n=113, 14%; P=.51). Digital medicine patients demonstrated improvements in HbA_1c (mean 7.3, SE 1.5 to mean 6.9, SE 1.2; P<.001) and significant changes in the proportion of patients with HbA_1c≥9.0 (n=107, 14% to n=49, 6%; P<.001), diabetes distress (n=198, 26% to n=122, 16%; P<.001), and hypoglycemic episodes (n=313, 41.1% to n=91, 11.9%; P<.001).

Conclusions

A digital diabetes program is associated with significant improvement in glycemic control and other diabetes measures. The use of a virtual health intervention using connected devices was widely accepted across a broad range of ethnic diversity, ages, and levels of health literacy.

Variation between general practitioners in type 2 diabetes processes of care

AIMS

To explore variation in general practitioners' (GPs') performance of six recommended procedures in type 2 diabetes patients <75 years without cardiovascular disease.

METHODS

Cross-sectional study of quality of diabetes care in Norway based on electronic health records from 2014. GPs (clustered in practices) were divided in quintiles based on a composite measure of performance of six processes of care. We fitted a multilevel partial ordinal regression model to identify GP factors associated with being in quintiles with better performance.

RESULTS

We identified 6015 type 2 diabetes patients from 275 GPs in 77 practices. The GPs performed on average 63.4% of the procedures; on average 46% in the poorest quintile to 81% in the best quintile with a larger range in individual GPs. After adjustments, use of a structured follow-up form was associated with GPs being in upper three quintiles (OR 12.4 (95% CI 2.37-65.1). Routines for reminders were associated with being in a better quintile (OR 2.6 (1.37-4.92). GPs' age >60 years and heavier workload were associated with poorer performance.

CONCLUSION

We found large variations in GPs' performance of processes of care. Factors reflecting structure and workload were strongly associated with performance.

Healthcare planning across healthcare sectors in Baden-Wuerttemberg, Germany: a stakeholder online survey to identify indicators

Background

Stakeholders in the German state of Baden-Wuerttemberg agreed upon the central aims for healthcare planning. These include a focus on geographical districts; a comprehensive, cross-sectoral perspective on healthcare needs and services; and use of regional data for healthcare planning. Therefore, healthcare data at district level is needed. Nevertheless, decision makers face the challenge to make a selection from numerous indicators and frameworks, which all have limitations or do not well apply to the targeted setting. The aim of this study was to identify district level indicators to be used in Baden-Wuerttemberg for the purpose of cross-sectoral and needs-based healthcare planning involving stakeholders of the health system.

Methods

A conceptual framework for indicators was developed. A structured search for indicators identified 374 potential indicators in indicator sets of German and international institutions and agencies (n = 211), clinical practice guidelines (n = 50), data bases (n = 35), indicator databases (n = 25), published literature (n = 35), and other sources (n = 18). These indicators were categorised according to the developed framework dimensions. In an online survey, institutions of various stakeholders were invited to assess the relevance of these indicators from December 2016 until January 2017. Indicators were selected in terms of a median value of the assessed relevance.

Results

22 institutions selected 212 indicators for the five dimensions non-medical determinants of health (20 indicators), health status (25), utilisation of the health system (34), health system performance (87), and healthcare provision (46).

Conclusions

Stakeholders assessed a large number of indicators as relevant for use in healthcare planning on district level.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06514-0.

Regional differences in COVID-19 ICU admission rates in the Kingdom of Saudi Arabia: A simulation of the new model of care under vision 2030

Objective

Saudi Arabia has succeeded in having one of the lowest rates of COVID-19 worldwide due to the government’s initiatives in taking swift action to control both the spread and severity of the virus. However, Covid-19 can serve as a test case of the expected response of the new healthcare system under Vision 2030. This study used data from the thirteen present administrative regions of KSA to simulate the variations in ICU admission as a quality indicator in the five business units proposed by a new Model of Care.

Methods

We determined the rates of ICU admission for patients with confirmed SARS-CoV-2 (COVID-19) from March to mid-July 2020. The final sample included 1743 inpatients with moderate to severe COVID-19. Patient characteristics, including demographics, pre-existing chronic conditions, and COVID-19 complications, were collected. Business units (BUs) were compared with respect to the relative odds of ICU admission by using multiple logistic regression.

Results

After keeping patient and clinical characteristics constant, clear BU differences were observed in the relative odds of ICU admission of COVID-19 patients. Inpatient admission to ICU in our total sample was almost 50%. Compared to the Central BU, the Northern and Western BUs showed significantly higher odds of ICU admission while the Eastern & Southern BUs had significantly lower odds.

Conclusion

ICU use for COVID-19 patients differed significantly in KSA healthcare BUs, consistent with variations in care for other non-COVID-19-related conditions. These differences cannot be explained by patient or clinical characteristics, suggesting quality-of-care differences. We believe that privatization and the shift to fewer administrative BUs will help lessen or eliminate altogether the present variations in healthcare service provision.

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services

OBJECTIVES

When research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation.

DESIGN

In this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation.

SETTING

Observational study of claims to mandatory health insurance in Switzerland in 2014.

PARTICIPANTS

Enrolees eligible for the 24 healthcare services.

PRIMARY OUTCOME MEASURES

The variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch's t-test.

RESULTS

The sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (-0.06 to 0.11) and 0.05 (-0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (-0.03 to 0.18) and 0.14 (-0.06 to 0.34), respectively) compared with positive recommendations.

CONCLUSIONS

In this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.

Urinary tract infection in patients with hip fracture

INTRODUCTION

Urinary tract infection (UTI) is a frequent complication of hip fractures. The Danish national clinical guideline for hip fracture recommends early and systematic mobilisation after surgery and that indwelling catheters are not used perioperatively.

AIMS

The aim of this study was to describe the number of patients who received nursing care to prevent UTIs in accordance with the recommendations from the national Danish clinical guidelines. Specifically, the aim was to report the number of patients developing UTIs during admission, have indwelling catheters removed and being mobilised with 24 hours after surgery.

METHODS

This prospective study included 65 patients. Data were collected on mobilisation and catheter use with a chart designed for this study. Sterile intermittent catheterisation was used to collect urine samples on admission and at discharge. Urine samples were sent for analysis at the microbiology laboratory. The urine sample was positive for UTI if the test showed 10⁴ CFU/ml bacteria.

RESULTS

A total of five patients contracted nosocomial UTI during their hospital stay (7.7%), while 29.2% of patients had a positive urine culture on admission and were treated for UTI. At discharge, 20% of the patients had a positive urine sample but no symptoms. Postoperatively, 52.3% of the patients were mobilised within 24 hours.

CONCLUSION

The incidence of nosocomial UTI was similar to what has been found in other studies (95% [CI], 0.03-0.17]). The percentage of patients with nosocomial UTI was 7.7%. Nursing care related to hygienic performance of catheterisation or intermittent catheterisation adhered to the Danish national clinical guidelines, and 52.3% of the patients were mobilised within 24 h after surgery, which showed low adherence to the guidelines.

Differences in nursing home admission between functionally defined populations in Germany and the association with quality of health care

Background

People prefer to age in place and not move into a nursing home as long as possible. The prevention of cognitive and functional impairments is feasible to support this goal. Health services play a key role in providing support for underlying medical conditions. We examined differentials in nursing home admissions between patient sharing networks in Germany and whether potential variations can be attributed to indicators of health care provision.

Methods

We conducted an ecological study using data of patients of 65 years and above from all 11 AOK statutory health insurance companies in Germany. Nursing home admissions were observed in a cohort of persons becoming initially care-dependent in 2006 (n = 118,213) with a follow-up of up to 10 years. A patient sharing network was constructed and indicators for quality of health care were calculated based on data of up to 6.6 million patients per year. Community detection was applied to gain distinct patient populations. Analyses were conducted descriptively and through regression analyses to identify the variation explained by included quality indicators.

Results

The difference in the proportion of nursing home admissions between identified clusters shows an interquartile range (IQR) of 12.6% and the average time between onset of care-dependency and admission to a nursing home an IQR of 10,4 quarters. Included quality indicators attributed for 40% of these variations for the proportion of nursing home admissions and 49% for the time until nursing home admission, respectively. Indicators of process quality showed the single highest contribution. Effects of single indicators were inconclusive.

Conclusions

Health services can support persons in their preference to age in place. Research and discussion on adequate health care for care-dependent persons and on conditions, where nursing home admission may be beneficial, is necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06196-8.

Practice Variation in Skin Cancer Treatment and Follow-Up Care: A Dutch Claims Database Analysis

BACKGROUND

Quality indicators are used to benchmark and subsequently improve quality of healthcare. However, defining good quality indicators and applying them to high-volume care such as skin cancer is not always feasible.

OBJECTIVES

To determine whether claims data could be used to benchmark high-volume skin cancer care and to assess clinical practice variation.

METHODS

All skin cancer care-related claims in dermatology in 2016 were extracted from a nationwide claims database (Vektis) in the Netherlands.

RESULTS

For over 220,000 patients, a skin cancer diagnosis-related group was reimbursed in 124 healthcare centres. Conventional excision reflected 75% of treatments for skin cancer but showed large variation between practices. Large practice variation was also found for 5-fluorouracil and imiquimod creams. The practice variation of Mohs micrographic surgery and photodynamic therapy was low under the 75th percentile, but outliers at the 100th percentile were detected, which indicates that few centres performed these therapies far more often than average. On average, patients received 1.8 follow-up visits in 2016.

CONCLUSIONS

Claims data demonstrated large practice variation in treatments and follow-up visits of skin cancer and may be a valid and feasible data set to extract quality indicators. The next step is to investigate whether detected practice variation is unwarranted and if a reduction improves quality and efficiency of care.

Breaking Barriers to Healthcare Access: A Multilevel Analysis of Individual- and Community-Level Factors Affecting Women's Access to Healthcare Services in Benin

Background: In low-income countries such as Benin, most people have poor access to healthcare services. There is scarcity of evidence about barriers to accessing healthcare services in Benin. Therefore, we examined the magnitude of the problem of access to healthcare services and its associated factors. Methods: We utilized data from the 2017–2018 Benin Demographic and Health Survey (n = 15,928). We examined the associations between the demographic and socioeconomic characteristics of women using multilevel logistic regression. The outcome variable for the study was problem of access to healthcare service. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CI) were estimated. Results: Overall, 60.4% of surveyed women had problems in accessing healthcare services. Partner’s education (AOR = 0.70; 95% CI; 0.55–0.89), economic status (AOR = 0.59; 95% CI; 0.47–0.73), marital status (AOR = 0.44; 95% CI; 0.39–0.51), and parity (AOR = 1.85; 95% CI; 1.45–2.35) were significant individual-level factors associated with problem of access to healthcare. Region (AOR = 5.24; 95% CI; 3.18–8.64) and community literacy level (AOR = 0.69; 95% CI; 0.51–0.94) were the main community-level risk factors. Conclusions: Enhancing husband education through adult education programs, economic empowerment of women, enhancing national education coverage, and providing priority for unmarried and multipara women need to be considered. Additionally, there is the need to ensure equity-based access to healthcare services across regions.

Reducing Imaging Utilization in Primary Care Through Implementation of a Peer Comparison Dashboard

BACKGROUND

High clinical variation has been linked to decreased quality of care, increased costs, and decreased patient satisfaction. We present the implementation and analysis of a peer comparison intervention to reduce clinical variation within a large primary care network.

OBJECTIVE

Evaluate existing variation in radiology ordering within a primary care network and determine whether peer comparison feedback reduces variation or changes practice patterns.

DESIGN

Radiology ordering data was analyzed to evaluate baseline variation in imaging rates. A utilization dashboard was shared monthly with providers for a year, and imaging rates pre- and post-intervention were retrospectively analyzed.

PARTICIPANTS

Providers within the primary care network spanning 1,358,644 outpatient encounters and 159 providers over a 3-year period.

INTERVENTIONS

The inclusion of radiology utilization data as part of a provider's monthly quality and productivity dashboards. This information allows providers to compare their practice patterns with those of their colleagues.

MAIN MEASURES

We measured provider imaging rates, stratified by modality, as well as order variation over time.

KEY RESULTS

We observed significant variation in imaging rates among providers in the network, with the top decile ordering an average of 4.2 times more than the lowest decile in the two years prior to intervention. Provider experience and training were not significantly associated with imaging utilization. In the first year after sharing utilization data with providers, we saw a 17.3% decrease in median imaging rate (p < 0.001) and a 21.4% reduction in provider variation between top and bottom deciles. Median ordering rate for more costly cross-sectional imaging, including CT, MRI, and nuclear medicine studies, decreased by 30.4% (p < 0.001), 20.2% (p = 0.008), and 41.8% (p = 0.002), respectively.

CONCLUSIONS

Peer comparison feedback can shape provider imaging behavior even in the absence of targets or financial incentives. Peer comparison is a low-touch, low-cost intervention for influencing provider ordering and may have applicability in other clinical areas.

Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years

PURPOSE

Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services.

METHODS

We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models.

RESULTS

The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: r_s = (-0.58), P = .03 and r_s = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95).

CONCLUSIONS

Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.

Degree of regional variation and effects of health insurance-related factors on the utilization of 24 diverse healthcare services - a cross-sectional study

Background

Regional variation in healthcare utilization could reflect unequal access to care, which may lead to detrimental consequences to quality of care and costs. The aims of this study were to a) describe the degree of regional variation in utilization of 24 diverse healthcare services in eligible populations in Switzerland, and b) identify potential drivers, especially health insurance-related factors, and explore the consistency of their effects across the services.

Methods

We conducted a cross-sectional study using health insurance claims data for the year of 2014. The studied 24 healthcare services were predominantly outpatient services, ranging from screening to secondary prevention. For each service, a target population was identified based on applicable clinical recommendations, and outcome variable was the use of the service. Possible influencing factors included patients’ socio-demographics, health insurance-related and clinical characteristics. For each service, we performed a comprehensive methodological approach including small area variation analysis, spatial autocorrelation analysis, and multilevel multivariable modelling using 106 mobilité spaciale regions as the higher level. We further calculated the median odds ratio in model residuals to assess the unexplained regional variation.

Results

Unadjusted utilization rates varied considerably across the 24 healthcare services, ranging from 3.5% (osteoporosis screening) to 76.1% (recommended thyroid disease screening sequence). The effects of health insurance-related characteristics were mostly consistent. A higher annual deductible level was mostly associated with lower utilization. Supplementary insurance, supplementary hospital insurance and having chosen a managed care model were associated with higher utilization of most services. Managed care models showed a tendency towards more recommended care. After adjusting for multiple influencing factors, the unexplained regional variation was generally small across the 24 services, with all MORs below 1.5.

Conclusions

The observed utilization rates seemed suboptimal for many of the selected services. For all of them, the unexplained regional variation was relatively small. Our findings confirmed the importance and consistency of effects of health insurance-related factors, indicating that healthcare utilization might be further optimized through adjustment of insurance scheme designs. Our comprehensive approach aids in the identification of regional variation and influencing factors of healthcare services use in Switzerland as well as comparable settings worldwide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05930-y.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study

BACKGROUND

One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care.

OBJECTIVE

We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care.

METHODS

The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout).

RESULTS

This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021.

CONCLUSIONS

Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18673.

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

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.

Variations in pediatric hospitalization in seven European countries

OBJECTIVE

To compare rates of pediatric hospital utilization across seven European countries.

METHODS

Secondary data from WHO's European Hospital Morbidity Database from 2009 to 2012. Cross- country comparison of rates of admissions and bed days per 100 person-years by clinical service. We tabulated counts of admissions and bed days by principal diagnosis and age group for Ireland, Austria, Hungary, Belgium, Spain, Germany, and France. ICD 9 or ICD 10 or ISHMT diagnosis codes were allocated to clinical services. Normal newborn admissions were excluded from the analysis. Simple linear regression models, weighted by pediatric population size, were constructed to estimate the relationships between health care utilization and factors that may influence variation in care.

RESULTS

Hospital admission across the seven countries ranged from 9.41 (Spain) to 19.59 (Germany) admissions per 100 person-years. Bed days ranged from a low of 52.50 (Spain) to 135.44 (Germany) per 100 person-years. General pediatrics and neonatology led in clinical volume across all countries. Infectious disease admissions were the third most common. Bed supply and nurse supply were positively associated with health care utilization. Out-of-pocket payment was inversely associated with health care utilization CONCLUSIONS: A wide range of utilization of pediatric inpatient care was observed across seven European countries that have universal coverage. Variation in the provision of effective, supply-sensitive, and preference-sensitive care may explain some of the variations. Our study shows that it is probable that preventable hospital admissions are occurring in the pediatric population.

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems

In the past decades, extensive research has been performed on the phenomenon of unwarranted clinical variation in clinical practice. Many studies have been performed on signaling, describing and visualizing clinical variation. We argue that it is time for next steps in practice variation research. In addition to describing and signaling variation patterns, we argue that a better understanding of causes of variation should be gained. Moreover, target points for improving and decreasing clinical variation should be created. Key elements in this new focus should be research on the complex interaction of networks, reflective medicine, patient beliefs and objective criteria for treatment choices. By combining these different concepts, alternative research objectives and new targets for improving and reducing unwarranted variation may be defined. In this perspective, we reflect on these concepts and propose target points for future research.

Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden

Background

One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively.

Methods

We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC).

Results

The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718).

Conclusions

Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.

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

RATIONALE, AIMS, AND OBJECTIVES

Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework.

METHOD

Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.

RESULTS

A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics).

CONCLUSION

Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care

OBJECTIVE

To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use.

DESIGN

Cross-sectional claims data study.

SETTING

The Netherlands.

PARTICIPANTS

Patients deceased in 2013-2015 with lung cancer (N = 25 553).

MAIN OUTCOME MEASURES

We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization.

RESULTS

The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level.

CONCLUSIONS

Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.

Communication training and the prescribing pattern of antibiotic prescription in primary health care

BACKGROUND

The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians.

METHODS

In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs.

RESULTS

Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

CONCLUSIONS

Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.