Addressing unwarranted clinical variation: A rapid review of current evidence

Harrison, Reema; Manias, Elizabeth; Mears, Stephen; Heslop, David; Hinchcliff, Reece; Hay, Liz

doi:10.1111/jep.12930

Cited by 41 publications

(42 citation statements)

References 36 publications

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“…However, despite this widespread and enduring interest in unwarranted clinical variation, the literature lacks strong conceptual frameworks to guide rigorous measurement and remediation efforts; and there are few typologies that systematically map the field . While the Dartmouth approach identifies three categories of care—namely, effective care (where variation implies some underuse of valid treatment), preference‐sensitive care (where variation implies more than one option of care is available and the exercising of patient choice), and supply‐sensitive care (where variation implies the volume of care provided is a reflection of capacity rather than patient need)—the distinction between what is warranted and unwarranted clinical variation remains poorly delineated …”

Section: Introductionmentioning

confidence: 99%

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

Sutherland¹,

Lévesque²

2019

Evaluation Clinical Practice

108

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Rationale, aims, and objectives: Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework. Method: Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.Results: A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics). Conclusion:Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework.This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation.From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

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Section: Introductionmentioning

confidence: 99%

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

Sutherland¹,

Lévesque²

2019

Evaluation Clinical Practice

108

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“…Furthermore, the optimal approach for reducing UCV is also unclear. In 2017, a review of approaches to address UCV highlighted that determining clinical variation that is unwarranted is a challenge for care decisions that may vary based on patient preferences or for which there is mixed evidence of its effectiveness [19].…”

Section: Introductionmentioning

confidence: 99%

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Harrison

Hinchcliff

Manias

et al. 2020

BMC Health Serv Res

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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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“…Identifying the optimal level of concordance, or what Harrison et al call identifying what is and is not unwarranted variation, is also challenging . Although concordance targets would ideally be evidence‐based, the complexity of pathways can make this difficult.…”

Section: Discussionmentioning

confidence: 99%

Concordance between Optimal Care Pathways and colorectal cancer care: Identifying opportunities to improve quality and reduce disparities

Bergin

Thomas

Whitfield

et al. 2019

Evaluation Clinical Practice

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Rationale, aims, and objectives: Care pathway policies for cancer aim to reduce variation and improve the quality of patient care, and there is increasing evidence that adherence to such pathways is associated with improved survival and lower health care costs. Australia is implementing Optimal Care Pathways (OCPs) for several cancers, including colorectal cancer, but studies evaluating how well care conforms to OCP recommendations are rare. This study examined concordance between OCP recommendations and colorectal cancer care prior to policy rollout and disparities for vulnerable populations.Method: Cross-sectional survey (2012-2014) of cancer registry-identified colorectal cancer patients aged ≥40 approached within 6 months of diagnosis (n = 433), their

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Addressing unwarranted clinical variation: A rapid review of current evidence

Cited by 41 publications

References 36 publications

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

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

Can feedback approaches reduce unwarranted clinical variation? A systematic rapid evidence synthesis

Concordance between Optimal Care Pathways and colorectal cancer care: Identifying opportunities to improve quality and reduce disparities

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