A systematic review of medical practice variation in OECD countries

Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study

Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register-based study in the Netherlands

INTRODUCTION

Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice.

MATERIAL AND METHODS

We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions.

RESULTS

Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (β = 0.11; P = 0.21) and therapeutic hysteroscopy rates (β = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (β = 0.10; P = 0.34) and negatively associated with both embolization rates (β = -0.08; P = 0.08) and myomectomy rates (β = -0.03; P = 0.82).

CONCLUSIONS

Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme

Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.

Temporal and geographical variations in diagnostic imaging in Norway

BACKGROUND

Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services.

OBJECTIVE

To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021.

METHODS

Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust.

CONCLUSION

As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.

External Vs Internal e-Referrals: Results from a Nationwide Epidemiological Study Utilizing Secondary Collected Data

Background

E-referral systems, streamlining patient access to specialists, have gained global recognition yet lacked a comparative study between internal and external referrals in Saudi Arabia (KSA).

Methods

This retrospective study utilized secondary data from the Saudi Medical Appointments and Referrals Centre system. The data covers 2020 and 2021, including socio-demographic data, referral characteristics, and specialties. Logistic regression analysis was used to assess factors associated with external referrals.

Results

Out of 645,425 e-referrals from more than 300 hospitals, 19.87% were external. The northern region led with 48.65%. Males were 55%, and those aged 25-64 were 56.68% of referrals. Outpatient clinic referrals comprised 47%, while 61% of referrals were due to a lack of specialty services. Several significant determinants are associated with higher rates of external referral with (p-value <0.001) and a 95% Confidence interval. Younger individuals under 25 exhibit higher referral rates than those aged 25-64. Geographically, compared to the central region, in descending order, there were increasing trends of external referral in the northern, western, and southern regions, respectively (OR = 19.26, OR = 4.48, OR 3.63). External referrals for outpatient departments (OPD) and dialysis services were higher than for routine admissions (OR = 1.38, OR = 1.26). The rate of external referrals due to the lack of available equipment was more predominant than other causes. Furthermore, in descending order, external referrals for organ transplantation and oncology are more frequent than for medical specialties, respectively (OR = 9.39, OR = 4.50).

Conclusion

The study reveals trends in e-referrals within the KSA, noting regional differences, demographic factors, and types of specialties regarding external referrals, benefiting the New Model of Care for the 2030 Vision. Findings suggest expanding virtual consultations to reduce external referrals. Strengthening primary care and preventive medicine could also decrease future referrals. Future studies should assess resource distribution, including infrastructure and workforce, to further inform healthcare strategy.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BACKGROUND

This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change.

METHODS

We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.

RESULTS

CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.

CONCLUSIONS

A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Q-Scoring System for the Evaluation of the Superficial Wound Swab Samples: A Clinical Microbiological Aspect

Purpose

Wound swab cultures are frequently requested from patients suspected of having a wound infection. The quality of the sample should also be evaluated by performing a Gram-stained microscopic examination. "Q-scoring system" is not widely used and the literature on the subject is limited.

Methods

A total of 4648 wound swab samples were evaluated. Samples with a Q-score of "0" were considered as "poor quality samples", and those with a score of " ≥ 1" were classified as "good quality samples". Microorganisms grown in the culture of samples that scored above one were identified by mass spectrometry, and antimicrobial susceptibility testing was performed.

Results

Gram stain results were found to be consistent with the culture result in 57.10% (n = 1078) of and inconsistent with the culture result in 42.90% (n = 813) of the samples. The number of samples with Q-scores one, two, and three among the 813 samples was 62, 29, and 722, respectively. The value observed in Q3 was found to be statistically significantly higher than the values observed in Q1 and Q2 (p < 0.05). Samples sent from surgical departments (61.92%) with a Q-score of ≥ 1, were statistically significant compared to internal medicine departments (p < 0.0001). There was no significant difference between samples sent from intensive care units and those sent from other inpatient services. For both groups with Q-scores ≥ 1 and "0" similar microorganisms were identified.

Conclusion

As a conclusion, the Q-scoring system will provide a common language between the laboratory and the clinic, especially by standardizing the evaluation of wound swab samples.

Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia

Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.

Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands

BACKGROUND

Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment.

METHODS

A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey.

RESULTS

Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist.

CONCLUSIONS

We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.

Defining practice variation and exploring influencing factors on needs assessment in home care nursing: A Delphi study

AIM

To describe a Delphi study regarding practice variation in needs assessment by Dutch home care nurses, to define practice variation in home care nursing and explore which factors may have a role in this needs assessment.

DESIGN

A Delphi study was conducted with the participation of home care representatives.

METHOD

A Delphi questionnaire was developed, preceded by literature research and an expert meeting. The Delphi study took place between December 2020 and February 2021. The goal was to achieve a consensus level of at least 70%.

RESULTS

After three rounds, 32 experts reached a consensus about definitions regarding variation in needs assessment, warranted and unwarranted variation. In total, 59 factors were determined related to (1) the client and health, (2) the clients' context, (3) nurses and (4) the nurses' context. Thirty-four factors scored warranted of influence and 18 (of 34) were client related. Most of the factors that scored unwarranted influencing needs assessment (17 of 26) were related to the home care nurses' context.

CONCLUSION

Having a consensus about the definition of practice variation in needs assessment and possible influencing factors support the professionals to discuss and improve the unity and quality of their decision-making process in home care. This may contribute to more righteous care for clients in need of home care.

IMPACT

Since 2015, home care nurses in the Netherlands are responsible for determining the amount, type and duration of care for clients in need of home care. This so-called needs assessment legitimizes the payment by health insurers. Signals of practice variation in needs assessment are heard in home care field. Although practice variation may be justified, it can lead to over or underuse of care, which may affect clients' outcomes. If we can identify influencing factors and find patterns that contribute to practice variation, we might gain a better understanding of the process and improve home care.

PATIENT OR PUBLIC CONTRIBUTION

In this study, there was no patient or public involvement. Client representatives were included in this research as experts in the home care field, and they participated in three rounds of the Delphi study. They contributed by sharing their expert opinion on the definitions presented and the factors possibly influencing needs assessment.

Unravelling the determinants of medical practice variation in referrals among primary care physicians: insights from a retrospective cohort study in Southern Israel

OBJECTIVES

Reducing medical practice variation (MPV) is a central theme of system improvement because it is associated with poor health outcomes, increased costs and disparities in care. This study aimed to estimate the extent to which each determinant (patient, physician, clinic) explains MPV among primary care physicians and to identify the characteristics of health services with a greater explained variance.

METHODS

A retrospective cohort study of primary care physicians practising in non-private clinics of Clalit Health Services in Southern Israel, for longer than a year between 2011 and 2017 and with more than 100 adult patients per practice. We assessed the variation in referral rates among 17 health services and the proportion explained by each domain (patient, physician and clinic). We used generalised linear negative binomial mixed models and the Nakagawa's R2, computing the marginal r2.

RESULTS

The study included 243 physicians working in 295 practices and 139 clinics. The mean-explained variance was 28.5%±10.0%, where physician characteristics explained 4.5% of the variation. The intrapractice variation (within a single physician between the years) was explained better than the interphysician (between physicians). Health services with high explained variation were blood tests characterised by both low intrapractice variation (Rs=-0.65, p value=0.005) and high referral rates (Rs=0.46, p value=0.06).

CONCLUSION

Over 70% of MPV is not explained by the patient, clinic and physician demographic and professional characteristics. Future research should focus on the fraction of MPV that is explained by the physicians' psychological characteristics, and thus potentially identify psychological targets for behavioural modifications aimed at reducing MPV.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Surgical trends and regional variation in Danish patients diagnosed with lumbar spinal stenosis between 2002 and 2018: a retrospective registry-based study of 83,783 patients

BACKGROUND

Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older people. However, surgery rates vary widely both internationally and nationally. This study compared patient and sociodemographic characteristics, geographical location and comorbidity between surgically and non-surgically treated Danish patients diagnosed with LSS from 2002 to 2018 and described variations over time.

METHODS

Diagnostic ICD-10 codes identifying patients with LSS and surgical procedure codes for decompression with or without fusion were retrieved from the Danish National Patient Register. Patients ≥ 18 years who had been admitted to private or public hospitals in Denmark between 2002 and 2018 were included. Data on age, sex, income, retirement status, geographical region and comorbidity were extracted. A multivariable logistic regression model was used to calculate the relative risk for surgically versus non-surgically treated LSS patients using the total population and subsequently divided into three time periods. Variations over time were displayed graphically.

RESULTS

A total of 83,783 unique patients with an LSS diagnosis were identified, and of these, 38,362 (46%) underwent decompression surgery. Compared to those who did not receive surgery, the surgically treated patients were more likely to be aged 65-74 years, were less likely to have comorbidities, had higher income and were more likely to reside in the northern part of Denmark. Patients aged 65-74 years remained more likely to receive surgery over time, although the difference between age groups eventually diminished, as older patients (aged ≥ 75) were increasingly more likely to undergo surgery. Large variations and differences in the relative risk of surgery were observed within and between the geographical regions. The likelihood of receiving surgery varied up to threefold between regions.

CONCLUSION

Danish patients with LSS who receive surgery differ in a number of respects from those not receiving surgery. Patients aged 65 to 74 years were more likely to receive surgery than other age groups, and LSS surgical patients were healthier, more often retired and had higher incomes than those not undergoing surgery. There were considerable variations in the relative risk of surgery between and within geographical regions.

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes

BACKGROUND

Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes.

METHODS

In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics.

FINDINGS

The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed.

CONCLUSION

Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Frameworks for estimating causal effects in observational settings: comparing confounder adjustment and instrumental variables

To estimate causal effects, analysts performing observational studies in health settings utilize several strategies to mitigate bias due to confounding by indication. There are two broad classes of approaches for these purposes: use of confounders and instrumental variables (IVs). Because such approaches are largely characterized by untestable assumptions, analysts must operate under an indefinite paradigm that these methods will work imperfectly. In this tutorial, we formalize a set of general principles and heuristics for estimating causal effects in the two approaches when the assumptions are potentially violated. This crucially requires reframing the process of observational studies as hypothesizing potential scenarios where the estimates from one approach are less inconsistent than the other. While most of our discussion of methodology centers around the linear setting, we touch upon complexities in non-linear settings and flexible procedures such as target minimum loss-based estimation and double machine learning. To demonstrate the application of our principles, we investigate the use of donepezil off-label for mild cognitive impairment. We compare and contrast results from confounder and IV methods, traditional and flexible, within our analysis and to a similar observational study and clinical trial.

Providers, peers and patients. How do physicians' practice environments affect patient outcomes?

We study how physicians' practice environments affect their treatment decisions and quality of care. Using clinical registry data from Sweden, we compare stent choices of cardiologists moving across hospitals over time. To disentangle changes in practice styles attributable to hospital- and peer group-specific factors, we exploit quasi-random variation on cardiologists working together on the same days. We find that migrating cardiologists' stent choices rapidly adapt to their new practice environment after relocation and are equally driven by the hospital and peer environments. In contrast, while decision errors increase, treatment costs and adverse clinical events remain largely unchanged despite the altered practice styles.

Between-Hospital and Between-Physician Variation in Outcomes and Costs in High- and Low-Complex Surgery: A Nationwide Multilevel Analysis

OBJECTIVES

Clinicians and policy makers are increasingly exploring strategies to reduce unwarranted variation in outcomes and costs. Adequately accounting for case mix and better insight into the levels at which variation exists is crucial for such strategies. This nationwide study investigates variation in surgical outcomes and costs at the level of hospitals and individual physicians and evaluates whether these can be reliably compared on performance.

METHODS

Variation was analyzed using 92 330 patient records collected from 62 Dutch hospitals who underwent surgery for colorectal cancer (n = 6640), urinary bladder cancer (n = 14 030), myocardial infarction (n = 31 870), or knee osteoarthritis (n = 39 790) in the period 2018 to 2019. Multilevel regression modeling with and without case-mix adjustment was used to partition variation in between-hospital and between-physician components for in-hospital mortality, intensive care unit admission, length of stay, 30-day readmission, 30-day reintervention, and in-hospital costs. Reliability was calculated for each treatment-outcome combination at both levels.

RESULTS

Across outcomes, hospital-level variation relative to total variation ranged between ≤ 1% and 15%, and given the high caseloads, this typically yielded high reliability (> 0.9). In contrast, physician-level variation components were typically ≤ 1%, with limited opportunities to make reliable comparisons. The impact of case-mix adjustment was limited, but nonnegligible.

CONCLUSIONS

It is not typically possible to make reliable comparisons among physicians due to limited partitioned variation and low caseloads. Nevertheless, for hospitals, the opposite often holds. Although variation-reduction efforts directed at hospitals are thus more likely to be successful, this should be approached cautiously, partly because level-specific variation and the impact of case mix vary considerably across treatments and outcomes.

Trauma-Related Clinical Practice Variation in Dutch Emergency Departments

Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.

Regional variations in lumbar spine surgery in Finland

INTRODUCTION

The regional variation in spine surgery rates has been shown to be large both within and between countries. This variation has been reported to be less in studies from countries with spine registers. The aim of this study was to describe the regional variation in lumbar spine surgery in Finland.

MATERIALS AND METHODS

This is a retrospective register study. Data from the Finnish National Hospital Discharge Register (NHDR) were used to calculate and compare the rates of lumbar disc herniation (LDH), decompression, and fusion surgeries in five University Hospital catchment areas, covering the whole Finnish population, from January 1, 1997, through December 31, 2018.

RESULTS

A total of 138,119 lumbar spine operations (including LDH, decompression, and fusion surgery) were performed in Finland between 1997 and 2018. The regional differences in the rate of LDH surgery were over fourfold (18 vs. 85 per 100,000 person years), lumbar decompression surgery over threefold (41 vs. 129 per 100,000 person years), and lumbar fusion surgery over twofold (14 vs. 34 per 100,000 person years) in 2018. The mean age of the patients increased in all regions during the study period.

CONCLUSIONS

In Finland, the regional variations in spine surgeries were vast. In a country with a publicly funded healthcare system, this finding was surprising. The recently created national spine register may serve to shed more light on the reasons for this regional variation.

Regional variation of medical expenditures attributable to hypertension in China's middle-aged and elderly population

BACKGROUND

Hypertension is a prevalent and costly health condition in China. Little is known about variation of the inpatient and outpatient expenditures attributable to hypertension between prefecture-level administrative regions (PARs) and the drivers of such variation among China's middle-aged and elderly population.

METHODS

We obtain data from China Health and Retirement Longitudinal Survey between 2011 and 2015, panel tobit models were used in our study to estimate differences across 122 PARs. Expenditure variation was explained by the characteristics of individuals and regions, including measures of healthcare supply.

RESULTS

The cost of treatment for patients with hypertension varies greatly geographically, with the highest outpatient and inpatient costs being 77 and 102 times the lowest, respectively. After adjustment for the individual and PAR character, there are associations between expenditure and region bed density.

CONCLUSION

There were significant regional differences in the outpatient and inpatient costs of middle-aged and elderly patients with hypertension in China, the difference between individuals may be an important reason, which has little to do with regional economic development differences, but is related to regional bed density.

Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives

Variation in patient outcomes among institutions and within institutions is a major problem in healthcare. Some of this variation is due to differences in practice, termed practice variation. Some practice variation is expected due to appropriately personalized care for a given patient. However, some practice variation is due to the individual preference or style of the clinicians. Quality improvement collaboratives are commonly used to disseminate quality care on a wide scale. Practice variation is a notable barrier to any quality improvement effort. A detailed and accurate understanding of practice variation can help optimize the quality improvement efforts. The traditional survey methods do not capture the complex nuances of practice variation. Vignette methods have been shown to accurately measure the actual practice variation and quality of care delivered by clinicians. Vignette methods are cost-effective relative to other methods of measuring quality of care. This review describes our experience and lessons from implementing vignette research methods in quality improvement collaboratives in California neonatal intensive care units. Vignette methodology is an ideal tool to address practice variation in quality improvement collaboratives, actively engage a large number of participants, and support more evidence-based practice to improve outcomes.

Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study

BACKGROUND

Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity.

OBJECTIVE

To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources.

METHODS

We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England.

RESULTS

On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others.

CONCLUSION

Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.

The Dartmouth Atlas of Health Care – bringing health care analyses to health systems, policymakers, and the public

In 1996, the Dartmouth Atlas of Health Care pioneered the dissemination of policy-relevant population-based measurement and analysis that revealed both weaknesses and opportunities in the United States health care system by focusing on regional and hospital variation in utilization, quality, and costs. Built on a growing foundation of peer-reviewed research, the Atlas produced more than 40 reports over the next 25 years addressing a wide range of pressing health care problems. The project’s publications and website also provided regional and hospital-specific data to health systems, governmental jurisdictions, health care stakeholders, and the public. The Atlas’ methods and its conceptual framework have been widely disseminated in North America and the United Kingdom, and, more recently, in Europe, South America, Asia, and Oceania. This paper discusses the origins of the Atlas from Dr. John Wennberg’s early studies, the scaling up of data, methods, and policy-relevant findings, and its incorporation into the more general fields of health services research, policy development, and clinical improvement.

Impact of advanced practice nurses in hospital units on compliance with clinical practice guidelines: a quasi-experimental study

BACKGROUND

Incorporating the best available evidence into clinical practice is a determining challenge for healthcare professionals and organisations. The role of advanced practice nurses is viewed as a facilitator to adapt guideline recommendations to suit specific contexts and to overcome barriers to implementation. In this study, we evaluate the impact of advanced practice nurses on clinical indicators of hospitalised patients and on adherence to recommendations derived from two clinical practice guidelines (pressure ulcer prevention and treatment and vascular access device management).

METHODS

Quasi-experimental study in five intervention (IU) and five control (CU) hospital units at three hospitals in Spain (period 2018-19). Five advanced practice nurses were incorporated into IU, with the intention that would produce attitudinal changes and enhance the skills and knowledge of the nursing team regarding 18 clinical practice recommendations. In this study, 41 indicators were evaluated through direct observation of all patients admitted, at monthly intervals for 1 year. Outcomes were assessed by means of a descriptive, multi-line regression and association analysis.

RESULTS

The study population was composed of 3742 inpatients admitted for pressure ulcer assessment and 2631 fitted with vascular access devices. By the end of the study period, all variables had improved in the IU, where average compliance with recommendations was statistically significantly higher (pressure ulcer guidance 7.9 ± 1.9 vs 6.0 ± 1.7. OR 1.86, 95% CI 1.67-2.05; vascular access devices guidance 5.4 ± 1.4 vs 4.4 ± 1,6. OR 1.06, 95% CI 0.95-1.17). The prevalence of pressure lesions and catheter-related adverse events decreased statistically significantly in the IU compared to the CU. The prevalence of pressure ulcers decreases (5.7% in IU vs 8.7% in CU p < 0.005) as well as the prevalence of adverse events related to the catheter (14% In IU vs 21.6% in CU p < 0.005). The unnecessary catheters decressed in IU 10.9% VS CU 15.8% (p < 0.005).

CONCLUSIONS

The incorporation of an advanced practice nurse statistically significantly improves clinical indicators related to the prevention and treatment of pressure ulcers and to the management of vascular access devices.

TRIAL REGISTRATION

ISRCTN18259923 retrospectively registered on 11/02/2022.

Identifying factors explaining practice variation in secondary stroke prevention in primary care: a cohort study based on all patients with ischaemic stroke in the Stockholm region

OBJECTIVES

The aim of this study was to describe the practice variation in dispensation of secondary stroke preventive drugs among patients at different primary care centres (PCCs) in Stockholm region and to identify factors that may explain the variation.

DESIGN

Cohort study using administrative data from the Stockholm region.

SETTING

Stockholm Health Care Region, Sweden, serving a population of 2.3 million inhabitants, hospital and PCC data.

PARTICIPANTS

All patients (n=9761) with ischaemic stroke treated in hospital from 1 July 2009 to 30 June 2014 were included. Of these, 7562 patients registered with 187 PCCs were analysed. Exclusion criteria were; deceased patients, age <18, haemorrhagic stroke and/or switching PCC.

PRIMARY AND SECONDARY OUTCOME MEASURES

As primary outcome the impact of PCC organisation variables and patient characteristics on the dispensation of statins, antiplatelets, antihypertensives and anticoagulants were analysed. Secondarily, the unadjusted practice variation of preventive drug dispensation of 187 PCCs is described.

RESULTS

There was up to fourfold practice variation in dispensation of all secondary preventive drugs. Factors associated with a lower level of dispensed statins were privately run PCCs (OR 0.91 (95% CI 0.82 to 1.00)) and the patient being woman. Increased statin use was associated with a higher number of specialists in family medicine (OR 1.03 (95% CI 1.01 to 1.05)) and a higher proportion of patients registered with a specific physician (OR 1.37 (95% CI 1.11 to 1.68)). Women had on average a lower number of dispensed antihypertensives.

CONCLUSIONS

A high practice variation for dispensation of all secondary preventive drugs was observed. Patient and PCC level factors indicating good continuity of care and high level of general practitioner education were associated with higher use of statins. Findings are of importance to policymakers as well as individual providers of care, and more research and actions are needed to minimise inequality in healthcare.

Inequity in the healthcare utilization among latent classes of elderly people with chronic diseases and decomposition analysis in China

BACKGROUND

Studies have shown chronic disease-based healthcare utilization inequity is common. Hence, exploring this issue can help in establishing targeted measures and protecting the rights and interests of vulnerable groups. Against this background, the purpose of this study is to explore the latent classification of elderly patients with chronic disease and compare healthcare utilization inequity among latent classes.

METHODS

This study used the data of 7243 elderly patient with chronic diseases collected from the China Health and Retirement Longitudinal Study in 2018. Latent class analysis was used to classify the patients with chronic diseases, and analysis of variance and [Formula: see text] tests were utilized to test the differences in characteristics among latent classes. Healthcare utilization inequity was measured based on the concentration index (CI), and the CI was decomposed to compare the horizontal index of healthcare utilization among the latent classes.

RESULTS

The patients with chronic diseases were divided into five latent classes, namely, the musculoskeletal system, hypertension, respiratory system, digestive system and cardiovascular system groups. Statistically significant differences in social demographic characteristics were observed among the five latent classes (P &lt; 0.05). A pro-rich healthcare utilization inequity for all respondents was observed (outpatient CI = 0.080, inpatient CI = 0.135), and a similar phenomenon in latent classes was found except for the musculoskeletal system group in outpatient visits (CI = -0.037). The digestive system group had the worst equity (outpatient CI = 0.197, inpatient CI = 0.157) and the respiratory system group had the best (outpatient CI = 0.001, inpatient CI = 0.086). After balancing the influence of health need factors, healthcare utilization inequity was almost alleviated. Furthermore, for all respondents, the contribution of health need factors (65.227% for outpatient and 81.593% for inpatient) was larger than that of socioeconomic factors (-21.774% for outpatient and 23.707 for inpatient), and self-rated health status was the greatest contributor (57.167% for outpatient and 79.399% for inpatient). The characteristics were shown in latent classes.

CONCLUSIONS

Healthcare utilization inequity still exists in elderly patients with chronic diseases, and the specific performances of inequity vary among latent classes. Moreover, self-rated health status plays an important role in healthcare utilization inequity. Providing financial support to low-income patients with certain chronic diseases, focusing on their physical and mental feelings and guiding them to evaluate their health status correctly could be essential for alleviating healthcare utilization inequity among elderly patients with chronic diseases.

Hierarchical medical system and local medical performance: A quasi-natural experiment evaluation in Shanghai, China

Background

In order to maintain high standards of healthcare, it is necessary for medical departments to provide high-quality and affordable medical services to local residents. This has been widely accepted in developed countries, while the medical treatment systems in developing countries remain to be improved. This research is based on a pilot of a hierarchical medical system in Shanghai, China, to evaluate the effects on policy of medical reform in developing countries.

Methods and results

By means of the difference-in-differences (DID) method, the causal relationship between medical care services' improvement and hierarchical medical systems' implementation could be identified. This project also explores the differential effects of policy intervention and confirms that the pilot showed a significant improvement in medical performance in central districts while the result remains uncertain in terms of suburban districts. Furthermore, the dynamic effect of a hierarchical medical system has also been identified with the event study method, while the policy pilot only had short-term effects on local medical resources' improvement. In order to ascertain the function mechanisms of hierarchical medical systems and explain why the policy pilot only had short-term effects, this project also conducts influencing mechanism analysis with the triple-differences method (also known as difference-in-difference-in-differences or DDD method). According to the empirical results, there is no direct evidence indicating the hierarchical medical system could bring obvious benefits from the perspectives of patients and medical institutions.

Conclusions

For better implementation of hierarchical medical systems in the future, long-term supervision mechanisms should be given more attention in the enforcement process of hierarchical medical systems. At the same time, more safeguarding measures should be implemented, such as supervising the payment systems of the medical institution and conducting performance evaluation.

Information needs and research priorities in long-term survivorship of breast cancer: Patients and health professionals' perspectives

OBJECTIVE

The objective of this work is to identify unmet information needs of long-term-survivors of breast cancer (BC) and future research needs from the perspectives of patients and health care professionals.

METHODS

Two online Delphi surveys were conducted. Participants in Survey 1 were patients. Participants in Survey 2 were health care professionals from both primary and secondary care involved in BC care. Both surveys included three successive rounds. The first round aimed to identify research and information needs; the second round aimed to rank the relative importance of those needs; the third round aimed to find consensus.

RESULTS

The most important information needs were self-management recommendations of common health problems after treatment and complications of breast reconstruction after 5 years. The most important research priorities were related to interventions and tools to increase information provision by professionals about certain tests, diet, and coordinated action between primary and specialised care during follow-up, and indications and safety issues of pregnancy in survivors.

CONCLUSIONS

Two fundamental ideas were identified: (1) Patients request information about self-management common health problems after treatment and breast reconstruction complications. (2) Health care professionals emphasise the need for a standardised approach based on protocols, recommendations, and coordinated actions in the provision of information.

IMPLICATIONS FOR CANCER SURVIVORS

Given the increasing number of BC survivors, it is essential to identify information and research needs to improve their care and health outcomes.

Who Pays the Cancer Tax? Patients’ Narratives in a Movement to Reduce Their Invisible Work

Many studies examine the division of labor inside organizations. Yet there is also an expected division of labor between organizations and their clients, which research to date has tended to ignore or has treated as static and easily accepted by both parties. How might clients change the expected division of labor with a service organization? We developed this question while studying an academic cancer center (ACC), where patient activists led a movement to bring to light the burdensome invisible work they and their families did to coordinate their treatment. They shared their own stories, developed formal channels for collecting more stories, and worked to broadcast the growing set of stories across ACC. Their stories became a resource for change and mobilized a coalition of staff allies. Coalition members drew on the patient stories to develop a new diagnostic framing of the “Cancer Tax”—the burdensome coordination work ACC required of patients. They also developed a prognostic frame for how ACC could help, which inspired a new program that took on some of the patients’ coordination tasks. In this way, the patients’ stories created new awareness of the problem and provided resources for staff allies to make the case for taking on some of the patients’ invisible work. This study shows that clients can effectively influence organizational change through movements fueled by personal narratives (for instance, lessening the coordination work they must do to coproduce complex services).

Methodology paper for the General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED): a retrospective cohort study of internal medicine resident case-mix, clinical care and patient outcomes

INTRODUCTION

Unwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards outcomes-based and competency-based medical education, current assessment strategies in residency do not routinely incorporate clinical outcomes. The widespread use of electronic health records (EHRs) may enable the implementation of in-training assessments that incorporate clinical care and patient outcomes.

METHODS AND ANALYSIS

The General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED) is a retrospective cohort study of senior residents (postgraduate year 2/3) enrolled in the University of Toronto Internal Medicine (IM) programme between 1 April 2010 and 31 December 2020. This study focuses on senior IM residents and patients they admit overnight to four academic hospitals. Senior IM residents are responsible for overseeing all overnight admissions; thus, care processes and outcomes for these clinical encounters can be at least partially attributed to the care they provide. Call schedules from each hospital, which list the date, location and senior resident on-call, will be used to link senior residents to EHR data of patients admitted during their on-call shifts. Patient data will be derived from the GEMINI database, which contains administrative (eg, demographic and disposition) and clinical data (eg, laboratory and radiological investigation results) for patients admitted to IM at the four academic hospitals. Overall, this study will examine three domains of resident practice: (1) case-mix variation across residents, hospitals and academic year, (2) resident-sensitive quality measures (EHR-derived metrics that are partially attributable to resident care) and (3) variations in patient outcomes across residents and factors that contribute to such variation.

ETHICS AND DISSEMINATION

GEMINI MedED was approved by the University of Toronto Ethics Board (RIS#39339). Results from this study will be presented in academic conferences and peer-reviewed journals.

Assessment of Temporal Patterns and Patient Factors Associated With Oseltamivir Administration in Children Hospitalized With Influenza, 2007-2020

IMPORTANCE

Oseltamivir therapy is recommended for all pediatric inpatients with influenza, particularly those with high-risk conditions, although data regarding its uptake and benefits are limited.

OBJECTIVE

To describe temporal patterns and independent patient factors associated with the use of oseltamivir and explore patterns in resource use and patient outcomes among children hospitalized with influenza.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter retrospective cross-sectional study was conducted at 36 tertiary pediatric hospitals participating in the Pediatric Health Information System in the US. A total of 70 473 children younger than 18 years who were hospitalized with influenza between October 1, 2007, and March 31, 2020, were included.

EXPOSURES

Hospitalization with a diagnosis of influenza.

MAIN OUTCOMES AND MEASURES

The primary outcome was the use of oseltamivir, which was described by influenza season and by hospital. Patient factors associated with oseltamivir use were assessed using multivariable mixed-effects logistic regression models. Secondary outcomes were resource use (including antibiotic medications, chest radiography, supplemental oxygen, positive pressure ventilation, central venous catheter, and intensive care unit [ICU]) and patient outcomes (length of stay, late ICU transfer, 7-day hospital readmission, use of extracorporeal membrane oxygenation, and in-hospital mortality), which were described as percentages per influenza season.

RESULTS

Among 70 473 children hospitalized with influenza, the median (IQR) age was 3.65 (1.05-8.26) years; 30 750 patients (43.6%) were female, and 39 715 (56.4%) were male. Overall, 16 559 patients (23.5%) were Black, 36 184 (51.3%) were White, 14 133 (20.1%) were of other races (including 694 American Indian or Alaska Native [1.0%], 2216 Asian [3.0%], 372 Native Hawaiian or Pacific Islander [0.5%], and 10 850 other races [15.4%]), and 3597 (5.1%) were of unknown race. A total of 47 071 patients (66.8%) received oseltamivir, increasing from a low of 20.2% in the 2007-2008 influenza season to a high of 77.9% in the 2017-2018 season. Use by hospital ranged from 43.2% to 79.7% over the entire study period and from 56.5% to 90.1% in final influenza season studied (2019-2020). Factors associated with increased oseltamivir use included the presence of a complex chronic condition (odds ratio [OR], 1.42; 95% CI, 1.36-1.47), a history of asthma (OR, 1.31; 95% CI, 1.23-1.38), and early severe illness (OR, 1.19; 95% CI, 1.13-1.25). Children younger than 2 years (OR, 0.81; 95% CI, 0.77-0.85) and children aged 2 to 5 years (OR, 0.83; 95% CI, 0.79-0.88) had lower odds of receiving oseltamivir. From the beginning (2007-2008) to the end (2019-2020) of the study period, the use of antibiotic medications (from 74.4% to 60.1%) and chest radiography (from 59.2% to 51.7%) decreased, whereas the use of oxygen (from 33.6% to 29.3%), positive pressure ventilation (from 10.8% to 7.9%), and central venous catheters (from 2.5% to 1.0%) did not meaningfully change. Patient outcomes, including length of stay (median [IQR], 3 [2-5] days for all seasons), readmissions within 7 days (from 4.0% to 3.4%), use of extracorporeal membrane oxygenation (from 0.5% to 0.5%), and in-hospital mortality (from 1.1% to 0.8%), were stable from the beginning to the end of the study period.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of children hospitalized with influenza, the use of oseltamivir increased over time, particularly among patients with high-risk conditions, but with wide institutional variation. Patient outcomes remained largely unchanged. Further work is needed to evaluate the impact of oseltamivir therapy in this population.

Regional variation in prescription drug spending: Evidence from regional migrants in Sweden

There is substantial variation in drug spending across regions in Sweden, which can be justified if caused by differences in health need, but an indication of inefficiencies if primarily caused by differences in place-specific supply-side factors. This paper aims to estimate the relative effect of individual demand-side factors and place-specific supply-side factors as drivers of geographical variation in drug spending in Sweden. We use individual-level register data on purchases of prescription drugs matched with demographic and socioeconomic data of a random sample of about 900,000 individuals over 2007-2016. The primary empirical approach is a two-way fixed effect model and an event study where we identify demand- and supply-side effects based on how regional and local migrants change drug spending when moving across regional and municipal borders. As an alternative approach in robustness checks, we also use a decomposition analysis. The results show that the place-specific supply-side effect accounts for only about 5%-10% of variation in drug spending and remaining variation is due to individual demand-side effects. These results imply that health policies to reduce regional variation in drug spending would have limited impact if targeted at place-specific characteristics.

Variation in the utilization of medical devices across Germany, Italy, and the Netherlands: A multilevel approach

Variation in healthcare utilization has been discussed extensively, with many studies showing that variation exists, but fewer studies investigating the underlying factors. In our study, we used a logistic multilevel-model at the patient, hospital, and regional levels to investigate (i) the levels to which variation could be attributed and (ii) the hospital and regional factors associated with treatment decisions. To do so, we used hospital discharge records for the years 2012-2016 in Germany and Italy and for 2014-2016 in the Netherlands combined with hospital and regional characteristics in nine case studies. We used a theoretical framework to categorize these case studies into effective, preference-sensitive, and supply-sensitive care. Our results suggest that most variation in the treatment decision can be attributed to the hospital level (e.g., case volume), whereas only a minor part is explained by regional characteristics. Italy had the highest share attributable to the regional level, whereas the Netherlands had the lowest. We observed less variation for procedures in the effective-care category compared to the preference- and supply-sensitive categories. Although our results were heterogeneous, we identified patterns in line with the theoretical framework for treatment categories, underlining the need to address variation differently depending on the category in question.

Hospitalization following pediatric kidney transplantation: An international comparison among a Canadian pediatric transplant center, North American Pediatric Renal Trials and Collaborative Studies, and Cooperative European Pediatric Renal Transplant Initiative registry data

BACKGROUND

There are several databases across the world that collect pediatric KT data. We compare the hospitalization outcomes for pediatric KT recipients from a large Canadian transplant center (SickKids database; The Hospital for Sick Children Kidney Transplantation Institutional Database), United States (NAPRTCS), and Europe (CERTAIN registry).

METHODS

An institutional retrospective review of KT was performed between 2000 and 2015. Baseline characteristics, duration of initial hospitalization/readmission at 1-5 and 6- to 11-month posttransplant, and 1-year graft survival data were collected. Corresponding data from the NAPRTCS 2014 Annual Transplant Report and CERTAIN registry were compared.

RESULTS

Posttransplant, patients from NAPRTCS had the shortest duration of hospitalization within the first month (10.4 days, SE 0.2), followed by SickKids (20.3 days, SE 0.7) and CERTAIN (25.5 days, SE 0.7). For both living and deceased donor populations, patients from SickKids were most likely to be hospitalized at 1- to 5-month posttransplant (82.4% [89/108]; 72.1% [98/136]), followed by Europe (52.1% [198/380]; 61.6% [501/813]) and United States (45.4% [2379/5241]; 51.4% [2517/4896]). Patients from Europe were most likely to be hospitalized at 6- to 12-month posttransplant (42.1% [160/380]; 51.7% [420/813]), followed by SickKids (35.2% [38/108]; 37.5% [51/136]) and United States (28.3% [1387/4901]; 31.6% [1411/4465]). Across all databases, the most commonly addressed issues during readmissions were infectious complications.

CONCLUSION

The differences observed in this investigation may reflect the local reimbursement models, resources for outpatient management, and practice variations across a large Canadian transplant center, United States, and European countries.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study

Background

A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need.

Methods

We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models – individuals and hospital regions – were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 − 2013 and 2014 − 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios.

Results

We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 − 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 − 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 − 2013, but only 5% in 2014 − 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially.

Conclusions

Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08305-7.

Geographic and temporal variation in the treatment and outcomes of atrial fibrillation: a population-based analysis of national quality indicators

BACKGROUND

Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada.

METHODS

In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS₂ score. We assessed geographic variation using small-area variation statistics and geospatial data analysis.

RESULTS

Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions.

INTERPRETATION

The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.

A physical therapist-led clinical decision-making program reduced risk of adverse events after total knee arthroplasty over 3 years: A retrospective review

CONTEXT

Reducing adverse events after total knee arthroplasty has implications for newly developed bundled payment models.

OBJECTIVE

To examine the impact of a physical therapist-led clinical decision-making program on the risk of adverse events, function, visits used, or reaching knee range of motion (ROM) goals in patients after total knee arthroplasty.

METHODS

The decision-making program consisted of quarterly meetings and recommendations for early risk identification and evidence-based intervention. A retrospective review of electronic records included adult patients who underwent total knee arthroplasty postoperative rehabilitation in an 18-month baseline period from 2014 to 2015 and an intervention period from 2015 to 2018. Relative risk reduction (RRR) determined whether a reduction in risk had occurred. Discharge function was measured with the Lower Extremity Functional Scale.

RESULTS

A total of 160 patients were included, 69 from the 18-month baseline period and 91 from the 36-month intervention period. Mean (SD) age was 68 (9.2) years in the baseline period and 72 (9.7) years in the intervention period. There was an 8.4% (95% CI, 1.1%-64.9%) RRR in adverse events. The RRR for patients not reaching full knee extension was 70.5% (95% CI, 33.4%-87.0%) and the RRR for patients not reaching 120° of knee flexion was 65.5% (95% CI, 5.4%-87.4%). There was significant improvement in the discharge function score (P = 0.05), but not the number of visits used (P = 0.29).

CONCLUSION

The physical therapist-led clinical decision-making program reduced the risk of adverse events after total knee arthroplasty. The risk of not reaching ROM goals by discharge was also substantially reduced.

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.