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

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.

SP4.1.6 Introduction of Concentric digital and remote consent into clinical practice during the COVID-19 pandemic

Introduction Paper-based consent processes are associated with errors of omission, illegibility and unwarranted variation. During the COVID-19 pandemic the Royal College of Surgeons (England) released guidelines supporting the use of remote consent. The aim was to evaluate the introduction of Concentric, a digital consent application, into clinical practice. Method Between April 2020-Jan 2021, Concentric was used optionally for medical consent during registered service evaluations. Data was obtained from Concentric analytics. User and patient feedback was obtained via optional satisfaction surveys. Results 3417 Concentric consent episodes for 356 unique procedures were performed by 170 clinicians across 16 specialties from 13 healthcare providers. Patients were aged 7-101years, (median 58, IQR 30). Of the completed consent episodes (n = 2799), consent was given; remotely in 23% of episodes, and on the day of surgery in 67%. Consent form information was shared digitally with 82% of patients. Average patient user experience was 8.8 out of 10 (1 very poor - 10 excellent, n = 594). 546/594 (91.9%) patients agreed that Concentric provided all the information they needed to know. Clinicians (n = 23) rated the quality of the consent process with Concentric as 4.8 out of 5 with all supporting the use of Concentric across the Trust. Conclusion Concentric has been successfully introduced into clinical practice. Patients and clinicians report high satisfaction scores. Remote consent is feasible and trends in consent practice, such as day of surgery consent can be easily identified and can guide quality improvement work. The introduction of digital consent solutions should be considered for all units.

Access to systemic anti-cancer therapies for women with secondary breast cancer—protocol for a mixed methods systematic review

Background It is well recognised that access and receipt of appropriate guideline recommended treatment with systemic anti-cancer therapies for secondary breast cancer is a key determinant in overall survival. Where there is disparity in access this may result in unwarranted variation and disparity in outcomes. Individual, clinical and wider contextual factors have been associated with these disparities, however this remains poorly understood for women with secondary breast cancer. The purpose of the review is to examine individual, clinical and contextual factors which influence access to evidence-based systemic anti-cancer therapies for women with secondary breast cancer. This will include barriers and facilitators for access and receipt of treatment and an exploration of women and clinicians experience and perspectives on access. Methods A mixed methods approach with a segregated design will be used to examine and explore factors which influence access to systemic anti-cancer therapies for women with secondary breast cancer. Electronic databases to be searched from January 2000 onwards will be EBSCO CINAHL Plus, Ovid MEDLINE, Ovid EMBASE, PsychINFO and the Cochrane Library and JBI database. This will include NHS Evidence which will be searched for unpublished studies and gray literature. Title and abstract citations and full-text articles will be screened by the author and second reviewer. Data will be extracted by the author and validated by the second reviewer. An overarching synthesis will be produced which brings together quantitative and qualitative findings. Methodological quality and risk of bias will be assessed using the Mixed Methods Appraisal Tool. Discussion Understanding individual, clinical and wider contextual factors associated with access and receipt of systemic anti-cancer therapies for secondary breast cancer is a complex phenomenon. These will be examined to determine any association with access. Review findings will be used to guide future research in this area and the development of an evidence-based service level intervention designed to address unwarranted variation in access based upon the Medical Research Council (MRC) approach to the development, implementation and evaluation of complex interventions. Systematic review registration The review protocol has been registered in PROSPERO CRD42020196490.

REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study

IntroductionSubstantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients’ outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care.Methods and analysisQuantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016–2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an ‘Implementation Toolkit’ to inform and improve commissioning and delivery of hip fracture services.Ethics and disseminationThis study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.

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

ObjectivesWhen research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation.DesignIn this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation.SettingObservational study of claims to mandatory health insurance in Switzerland in 2014.ParticipantsEnrolees eligible for the 24 healthcare services.Primary outcome measuresThe variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch’s t-test.ResultsThe sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (−0.06 to 0.11) and 0.05 (−0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (−0.03 to 0.18) and 0.14 (−0.06 to 0.34), respectively) compared with positive recommendations.ConclusionsIn this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.

Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice

ObjectivesDespite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.DesignSemistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.ParticipantsGeneral practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.SettingGeneral practices and NHS organisations in England.ResultsInterviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers’ professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.ConclusionPrescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.