Addressing unwarranted variations in colorectal cancer outcomes: a conceptual approach

Abstract

In the clinical setting, the term 'unwarranted variation' refers to variations in patient outcomes that cannot be explained by the patient's underlying illness or medical needs, or the dictates of evidence-based medicine. These types of variations persist even after adjusting for patient-specific factors. Unwarranted variation depends on a complex mix of disparities, including inequalities in access to appropriate care in a wide variety of geographical and cultural settings, in the uptake and application of clinical knowledge, in the prioritization and allocation of resources, and differences in organizational and professional culture. Nevertheless, unwarranted variation has been inexorably linked with clinical practice. Thus, awareness of the antecedents of unwarranted variations in clinical practice is strategically important. In this Perspective, we discuss these antecedents in colorectal cancer clinical care pathways with an emphasis upon the multidisciplinary team (MDT), and suggest pragmatic steps that could be taken to address latent unwarranted variation.

Addressing unwarranted clinical variation: A rapid review of current evidence

“…Five studies described 6 frameworks that are used for understanding clinical care variation . The uncertainty hypothesis and Wennberg's classification system is presented as a framework for understanding clinical care variation, setting out the effective‐care, preference sensitive care, and supply‐sensitive care categories .…”

“…The uncertainty hypothesis and Wennberg's classification system is presented as a framework for understanding clinical care variation, setting out the effective‐care, preference sensitive care, and supply‐sensitive care categories . A further study uses the uncertainty hypothesis proposed by Wennberg and Gittelsohn, along with Wennberg's classification system for categorizing clinical care variation, to form the basis of the Atlas of Variations in Medical Practice in Spain . Bernal‐Delgado and colleagues modified the original Wennberg classification system that was developed in a US context, for relevance in Europe and specifically in Spain.…”

“…The value attribute assesses utilization rates of a particular practice to determine whether utilization is at an “acceptable” level based on average utilization rates. A determination is made as to whether any given practice is being undertaken at a statistically significant rate outside of the defined parameters . The variation‐attribute indicates whether differences observed across environments can be considered “unwarranted” based on statistical analysis.…”

“…The variation‐attribute indicates whether differences observed across environments can be considered “unwarranted” based on statistical analysis. The Atlas draws upon the uncertainty hypothesis to set the statistical parameters and therefore determines whether variation in practice is unwarranted …”

“…Two groups of studies reported approaches to determine UCV, with suggestions to address UCV. The first group of 4 studies applied a framework to determine UCV in population or hospital level data . The second group of 14 studies applied statistical models, most commonly regression analyses, to identify variation that was considered to be deviating at a statistically significant level from standard, appropriate or expected levels of variability …”