Unwarranted Variation in Healthcare: Impacts of Test-Order Practice Variation on Care-Delivery Cost

2021 ◽  
Vol 2021 (1) ◽  
pp. 16436
Author(s):  
Seokjun Youn ◽  
Gregory Raymond Heim
Keyword(s):  
Care Delivery ◽  
Practice Variation ◽  
Delivery Cost ◽  
Test Order ◽  
Unwarranted Variation

Moving toward patient-based funding through quality-based procedures (QBPs) for GI endoscopy and colposcopy.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 43-43
Author(s):  
Nabeela Ratansi ◽  
Aimee Langan ◽  
Irene Blais ◽  
Erin Svara ◽  
Karla Houser ◽  
...  
Keyword(s):  
Best Practices ◽  
Performance Management ◽  
Capacity Planning ◽  
Best Practice ◽  
Care Delivery ◽  
Clinical Pathways ◽  
Quality Care ◽  
Practice Variation ◽  
Evidence Based ◽  
Gi Endoscopy

43 Background: As part of the Ministry’s Health System Funding Reform initiative, Cancer Care Ontario is tasked to develop and implement Quality-Based Procedures (QBPs) for programs such as GI Endoscopy and Colposcopy. QBPs are clusters of patients with clinically related diagnoses or treatments that have been identified by an evidence-based framework as providing opportunity for improving quality outcomes and reducing costs. As stated by the Ministry, the goal is to reimburse providers for the types and numbers of patients treated, using evidence-informed rates associated with the quality of care delivered. Methods: QBPs are multiyear and have four key deliverables: Clinical: developing clinical best practices. Funding: tying best practices to pricing. Capacity Planning: understanding procedure types/volumes for capacity management. Monitoring/Evaluation: measuring the QBP’s impact. Developing the QBPs has involved: Creating Clinical Expert Advisory Groups (CEAG) of clinicians who are recognized for their knowledge and expertise. Tasking the CEAG to define quality and develop best practices informed by literature reviews, jurisdictional scans, and guidelines. Documenting these standards and clinical pathways in a clinical handbook, providing information on the practices that should be implemented to ensure consistent care delivery. The development of best practices is imperative to the foundation of the QBP and spans multiple years. Once best practice development is complete, it will be tied to pricing, where the procedure will be micro-costed based on workload, equipment, supplies, and other administrative costs. Results: The QBPs continue to evolve and aim to: Reduce practice variation. Improve patient outcomes. Improve system accountability. Improve cost-effectiveness of services. Effectiveness will be measured through a performance management framework, including an integrated QBP scorecard measuring appropriateness, access, and efficiency. Conclusions: The underpinning for moving towards an evidence-based, patient-based funding model involves defining quality standards and clincal best practices, and applying these guidelines to determine the cost of quality care.

scholarly journals Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes

2021 ◽  
pp. 219256822110648
Author(s):  
Juliëtte J. C. M. Van Munster ◽  
Vera de Weerdt ◽  
Ilan J. Y. Halperin ◽  
Amir H. Zamanipoor Najafabadi ◽  
Peter Paul G. van Benthem ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Clinical Practice ◽  
Literature Review ◽  
Degenerative Disc Disease ◽  
Practice Variation ◽  
Case Mix ◽  
Disc Disease ◽  
Explanatory Variables ◽  
Unwarranted Variation ◽  
Over Time

Study Design Literature review. Objective To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time. Methods Literature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman’s rho was used to determine the association between the Extreme Quotient (EQ) and year of publication. Results We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= −.33, P= .09). Conclusions Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

scholarly journals How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine

2018 ◽  
Vol 28 (9) ◽  
pp. 1486-1498 ◽  
Author(s):  
Markus A. Feufel
Keyword(s):  
Emergency Medicine ◽  
Care Delivery ◽  
Practice Variation ◽  
Emergency Physicians ◽  
Unmet Expectations ◽  
Variation In Care ◽  
Medical Need ◽  
Equity And Efficiency ◽  
Underlying Mechanisms

Forty years of statistical database analyses have demonstrated the existence of unwarranted practice variation in care delivery, that is, variations independent of medical need, evidence, or patient preference. Alas, little is known about the underlying mechanisms and thus finding interventions to reduce unwarranted variations remains difficult, hampering quality, equity, and efficiency of care. Whereas statistical analyses describe deviations from ideal patterns, ethnographically inspired analyses aim at understanding when, how, and why variations occur in practice. Based on case studies derived from shadowing emergency physicians, I demonstrate that analyzing practice variation in practice helps to (a) advance the understanding of mechanisms and (b) evaluate/expand the existing repertoire of interventions. Results revealed unmet expectations and new sources of known variations as well as interventions complementing systemic changes with those that empower individuals to better cope with the existing system. These findings highlight the benefits of mixed-methods for understanding and tackling practice variation.

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

2020 ◽  
Vol 32 (4) ◽  
pp. 271-274
Author(s):  
Femke Atsma ◽  
Glyn Elwyn ◽  
Gert Westert
Keyword(s):  
Clinical Practice ◽  
Network Effects ◽  
Practice Variation ◽  
Future Research ◽  
Patient Beliefs ◽  
The Past ◽  
Variation Patterns ◽  
Alternative Research ◽  
Clinical Variation ◽  
Unwarranted Variation

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

scholarly journals How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e029879
Author(s):  
Marco J Moesker ◽  
Janke F de Groot ◽  
Nikki L Damen ◽  
Menno V Huisman ◽  
Martine C de Bruijne ◽  
...  
Keyword(s):  
Outcome Measures ◽  
Care Delivery ◽  
Hospital Performance ◽  
Practice Variation ◽  
Patient Record ◽  
Bleeding Complications ◽  
Secondary Outcome ◽  
Supporting Evidence ◽  
Process Measures ◽  
Record Review

ObjectivesSurgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.DesignA multicentre retrospective patient record review.Setting and participantsRecords from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.Primary and secondary outcome measuresOur primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.ResultsPreoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%–100%), international normalised ratio testing (range 21%–94%) and postoperative bridging (range 20%–88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients’ weight.ConclusionsUnsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.

Testicular cancer management: Population-wide, rapid case ascertainment to drive early expert engagement and reduced practice variation.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 39-39
Author(s):  
Andrea Harzstark ◽  
Lisa J. Herrinton ◽  
Lauren C. Walker ◽  
Liyan Liu ◽  
Tatjana Kolevska ◽  
...  
Keyword(s):  
Decision Making ◽  
Testicular Cancer ◽  
Care Delivery ◽  
Research Priorities ◽  
Practice Variation ◽  
Practice Change ◽  
Cancer Management ◽  
Case Ascertainment ◽  
Early Results ◽  
Expert Team

39 Background: Research priorities in germ cell tumor (GCT) management have moved sharply from therapeutic improvements to cancer care delivery research and biomarker-based decision making. Early intervention with centralized decision support and oversight by expert teams result in best therapeutic outcomes and survivorship with decreased resource utilization. We describe Kaiser Permanente Northern California’s (KPNC) re-organization of care delivery through rapid case ascertainment and early expert input, as well as early results of reduction in practice variation and system-wide practice change. Methods: In 2016, KPNC reorganized oncology from a distributed generalist model to a model led by a centralized multidisciplinary expert team to share in initial and ongoing care delivery for all GCT patients in the system. Central to the re-organization was rapid ascertainment of the entire population of patients with GCT within the system and early expert engagement in treatment decision-making. Results: Between May 2016 and June 2018, 274 GCT patients were recorded in the tumor registry, of whom 69% were < 40 years of age, 16% were non-white, 56% had seminoma and 63% had stage 1 disease. Rapid case ascertainment identified 89% (95% CI, 86-93%) of the cases, increasing from 79% in 2016 to 97% in 2018 as false negatives were identified and used to improve the case finding algorithm. The overall positive predictive value was 57% (52-62%) and number needed to detect was 1.75 (1.62-1.91). Of the 274 cases, 92% (89-95%) were engaged by the expert team. In addition, the team reviewed 61 testicular cancer patients who had recurrences or metastatic cancers. Among 177 patients with stage I seminoma, the preferred use of active surveillance over adjuvant chemotherapy or radiation therapy rose from 48% (95% CI, 35-62%) in 2015 to 87% (75-99%) in 2018 (p = 0.0005). For patients with nonseminoma, the rate of the preferred option of retroperitoneal lymphadenectomies being performed by a high volume urologic surgeon increased markedly from 62% in 2015 to 95% in 2018. Conclusions: To our knowledge, the KPNC re-organization of GCT care delivery with comprehensive rapid case ascertainment is unique for integrated health care delivery systems in the USA. While early, KPNC has a working platform for early, expert multidisciplinary review and bidirectional communication with local care teams for population-based care. Early evidence points to system-wide reductions in practice variation and improvements in practice.

A Qualitative Examination of User Perceptions of User-Driven and App-Controlled Hearing Technologies

2019 ◽  
Vol 28 (4) ◽  
pp. 993-1005 ◽  
Author(s):  
Gitte Keidser ◽  
Nicole Matthews ◽  
Elizabeth Convery
Keyword(s):  
Hearing Aids ◽  
Care Delivery ◽  
Hearing Aid ◽  
New Technology ◽  
Successful Implementation ◽  
Semistructured Interview ◽  
User Perceptions ◽  
Template Analysis ◽  
Training And Support ◽  
And Training

Purpose The aim of this study was to examine how hearing aid candidates perceive user-driven and app-controlled hearing aids and the effect these concepts have on traditional hearing health care delivery. Method Eleven adults (3 women, 8 men), recruited among 60 participants who had completed a research study evaluating an app-controlled, self-fitting hearing aid for 12 weeks, participated in a semistructured interview. Participants were over 55 years of age and had varied experience with hearing aids and smartphones. A template analysis was applied to data. Results Five themes emerged from the interviews: (a) prerequisites to the successful implementation of user-driven and app-controlled technologies, (b) benefits and advantages of user-driven and app-controlled technologies, (c) barriers to the acceptance and use of user-driven and app-controlled technologies, (d) beliefs that age is a significant factor in how well people will adopt new technology, and (e) consequences that flow from the adoption of user-driven and app-controlled technologies. Specifically, suggested benefits of the technology included fostering empowerment and providing cheaper and more discrete options, while challenges included lack of technological self-efficacy among older adults. Training and support were emphasized as necessary for successful adaptation and were suggested to be a focus of audiologic services in the future. Conclusion User perceptions of user-driven and app-controlled hearing technologies challenge the audiologic profession to provide adequate support and training for use of the technology and manufacturers to make the technology more accessible to older people.

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