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Dominiek C, Natasha D, Foureur M, Spear V, Amanda H. Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section. Women Birth 2020; 34:352-361. [PMID: 32674990 DOI: 10.1016/j.wombi.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. AIM To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. METHODS A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 "evidence-based" statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. FINDINGS Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications "valid" compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. DISCUSSION Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. CONCLUSION Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.
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Affiliation(s)
- Coates Dominiek
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia.
| | - Donnolley Natasha
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, UNSW, Sydney, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Virginia Spear
- Royal Hospital for Women, South Easters Sydney Local Health District, Australia
| | - Henry Amanda
- School of Women's and Children's Health, UNSW Medicine, UNSW, Sydney, Australia; Department of Women's and Children's Health, St George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia.
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Harrison R, Hinchcliff RA, Manias E, Mears S, Heslop D, Walton V, Kwedza R. Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis. BMC Health Serv Res 2020; 20:40. [PMID: 31948447 PMCID: PMC6966854 DOI: 10.1186/s12913-019-4860-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/22/2019] [Indexed: 01/07/2023] Open
Abstract
Background Assessment of clinical variation has attracted increasing interest in health systems internationally due to growing awareness about better value and appropriate health care as a mechanism for enhancing efficient, effective and timely care. Feedback using administrative databases to provide benchmarking data has been utilised in several countries to explore clinical care variation and to enhance guideline adherent care. Whilst methods for detecting variation are well-established, methods for determining variation that is unwarranted and addressing this are strongly debated. This study aimed to synthesize published evidence of the use of feedback approaches to address unwarranted clinical variation (UCV). Methods A rapid review and narrative evidence synthesis was undertaken as a policy-focused review to understand how feedback approaches have been applied to address UCV specifically. Key words, synonyms and subject headings were used to search the major electronic databases Medline and PubMed between 2000 and 2018. Titles and abstracts of publications were screened by two reviewers and independently checked by a third reviewer. Full text articles were screened against the eligibility criteria. Key findings were extracted and integrated in a narrative synthesis. Results Feedback approaches that occurred over a duration of 1 month to 9 years to address clinical variation emerged from 27 publications with quantitative (20), theoretical/conceptual/descriptive work (4) and mixed or multi-method studies (3). Approaches ranged from presenting evidence to individuals, teams and organisations, to providing facilitated tailored feedback supported by a process of ongoing dialogue to enable change. Feedback approaches identified primarily focused on changing clinician decision-making and behaviour. Providing feedback to clinicians was identified, in a range of a settings, as associated with changes in variation such as reducing overuse of tests and treatments, reducing variations in optimal patient clinical outcomes and increasing guideline or protocol adherence. Conclusions The review findings suggest value in the use of feedback approaches to respond to clinical variation and understand when action is warranted. Evaluation of the effectiveness of particular feedback approaches is now required to determine if there is an optimal approach to create change where needed.
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Affiliation(s)
- Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Samuels Building (f25), Sydney, NSW, 2052, Australia.
| | - Reece Amr Hinchcliff
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, 4059, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Steven Mears
- Information Specialist, Hunter New England Medical Library, New Lambton, NSW, 2350, Australia
| | - David Heslop
- School of Public Health and Community Medicine, University of New South Wales, Samuels Building (f25), Sydney, NSW, 2052, Australia
| | - Victoria Walton
- Cancer Institute New South Wales, Level 9, 8 Central Avenue, Australian Technology Park, Eveleigh NSW 2015, PO Box 41, Alexandria, NSW, 1435, Australia
| | - Ru Kwedza
- Cancer Institute New South Wales, Level 9, 8 Central Avenue, Australian Technology Park, Eveleigh NSW 2015, PO Box 41, Alexandria, NSW, 1435, Australia.,Centre for Rural Health-North Coast, School of Rural Health, University of Sydney, Lismore, New South Wales, Australia
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Coates D, Homer C, Wilson A, Deady L, Mason E, Foureur M, Henry A. Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines. Women Birth 2019; 33:22-34. [PMID: 31253513 DOI: 10.1016/j.wombi.2019.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making. METHOD A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers. FINDINGS In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines. CONCLUSION The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.
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Affiliation(s)
- Dominiek Coates
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Australia.
| | - Caroline Homer
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Burnet Institute, Victoria, Australia
| | - Alyssa Wilson
- Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia
| | - Louise Deady
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Elizabeth Mason
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St. George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia
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Streit S, Verschoor M, Rodondi N, Bonfim D, Burman RA, Collins C, Biljana GK, Gintere S, Gómez Bravo R, Hoffmann K, Iftode C, Johansen KL, Kerse N, Koskela TH, Peštić SK, Kurpas D, Mallen CD, Maisoneuve H, Merlo C, Mueller Y, Muth C, Šter MP, Petrazzuoli F, Rosemann T, Sattler M, Švadlenková Z, Tatsioni A, Thulesius H, Tkachenko V, Torzsa P, Tsopra R, Canan T, Viegas RPA, Vinker S, de Waal MWM, Zeller A, Gussekloo J, Poortvliet RKE. Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries. BMC Geriatr 2017; 17:93. [PMID: 28427345 PMCID: PMC5399328 DOI: 10.1186/s12877-017-0486-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/11/2017] [Indexed: 01/13/2023] Open
Abstract
Background In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision. Methods Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP. Results The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs’ decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48–0.59; ORs per country 0.11–1.78). Conclusions Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0486-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Marjolein Verschoor
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daiana Bonfim
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Gerasimovska Kitanovska Biljana
- Department of Nephrology and Department of Family Medicine, University Clinical Centre, University St. Cyril and Metodius, Skopje, Macedonia
| | - Sandra Gintere
- Faculty of Medicine, Department of Family Medicine, Riga Stradiņs University, Riga, Latvia
| | - Raquel Gómez Bravo
- Institute for Health and Behaviour, Research Unit INSIDE, University of Luxembourg, Luxembourg, Luxembourg
| | - Kathryn Hoffmann
- Department of General Practice and Family Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Claudia Iftode
- Timis Society of Family Medicine, Sano Med West Private Clinic, Timisoara, Romania
| | | | - Ngaire Kerse
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Tuomas H Koskela
- Department of General Practice, University of Tampere, Tampere, Finland
| | - Sanda Kreitmayer Peštić
- Family Medicine Department, Health Center Tuzla, Medical School, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Donata Kurpas
- Family Medicine Department, Wroclaw Medical University, Wrocław, Poland
| | - Christian D Mallen
- Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Hubert Maisoneuve
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Merlo
- Institute of Primary and Community Care Lucerne (IHAM), Lucerne, Switzerland
| | - Yolanda Mueller
- Institute of Family Medicine Lausanne (IUMF), Lausanne, Switzerland
| | - Christiane Muth
- Institute of General Practice, Goethe-University, Frankfurt / Main, Germany
| | - Marija Petek Šter
- Department for Family Medicine, Medical faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Ferdinando Petrazzuoli
- SNAMID (National Society of Medical Education in General Practice), Prata Sannita, Italy.,Department of Clinical Sciences in Malmö, Centre for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Thomas Rosemann
- Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Sattler
- SSLMG, Societé Scientifique Luxembourgois en Medicine generale, Luxembourg, Luxembourg
| | | | - Athina Tatsioni
- Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Hans Thulesius
- Family Medicine, Department of Clinical Sciences, Lund University, Malmö and senior researcher Region Kronoberg, Växjö, Sweden
| | - Victoria Tkachenko
- Department of Family Medicine, Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Peter Torzsa
- Department of Family Medicine, Semmelweis University, Budapest, Hungary
| | - Rosy Tsopra
- LIMICS, INSERM, U1142, F-75006 Paris, Université Paris 13, Sorbonne Paris Cité, UMR_S 1142, F93000 Bobigny, Sorbonne Universités, UPMC Université Paris 06, UMR_S 1142, F75006 Paris, Paris, France.,Leeds Centre for Respiratory Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Tuz Canan
- Family Medicine Specialist, Kemaliye Town Hospital, Erzincan University, Erzincan, Turkey
| | - Rita P A Viegas
- Family Doctor, Invited Assistant of the Department of Family Medicine, NOVA Medical School, Lisbon, Portugal
| | - Shlomo Vinker
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Margot W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands
| | - Andreas Zeller
- Centre for Primary Health Care (uniham-bb), Basel, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands.
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Pellet AC, Erten MZ, James TA. Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost. Am J Surg 2015; 211:1084-8. [PMID: 26545344 DOI: 10.1016/j.amjsurg.2015.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/23/2015] [Accepted: 08/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients. METHODS A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded. RESULTS From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905. CONCLUSIONS Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost.
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Affiliation(s)
- Andrew C Pellet
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Mujde Z Erten
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Ted A James
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA.
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