Is there much variation in variation? Revisiting statistics of small area variation in health services research

Ibáñez, Berta; Librero, Julián; Bernal‐Delgado, Enrique; Peiró, Salvador; López-Valcarcel, Beatríz González; Martínez, Natalia; Aizpuru, Felipe

doi:10.1186/1472-6963-9-60

Cited by 68 publications

(70 citation statements)

References 27 publications

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“…This novel measure of variation is more robust than some conventional crude measures of variation such as the extremal quotient or CV. 21,188 We adjusted for a wide range of variables likely to be associated with clinical need, including the demographic composition of PCTs and the prevalence of chronic disease and markers of unhealthy lifestyles. The remaining, unexplained, geographical variation in procedure rates is therefore unlikely to be solely due to random fluctuations on practice or variation in clinical need.…”

Section: Strengths and Limitations Of The Projectmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Strengths and Limitations Of The Projectmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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“…En segundo lugar se describió, también por hospitales, el volumen de partos de bajo riesgo conforme a las especificaciones del indicador, sus características en cuanto a edad de la madre, edad gestacional, peso del RN y el porcentaje de cesáreas realizado sobre estos partos. A continuación se analizó la variabilidad entre hospitales para el indicador crudo y el indicador de bajo riesgo usando los estadísticos clásicos del análisis de variaciones en la práctica médica 17 : la razón de variación (RV; razón entre los hospitales con el porcentaje máximo y mínimo de cesá-rea), el coeficiente de variación (CV), el CV ponderado (CVw) por el número de partos en cada hospital, el componente sistemático de la variación (CSV) y Ji al cuadrado (χ 2 ). Estos estadísticos se calcularon para todos los hospitales excluyendo los que tenían porcentajes de cesárea por fuera de los percentiles [P] P5 y P95 o P25 y P75 (RV5-95, RV25-75, CV5-95, CVW5-95 y CSV5-95).…”

Section: Materials Y Métodosunclassified

Porcentaje de cesáreas en mujeres de bajo riesgo: un indicador útil para comparar hospitales que atienden partos con riesgos diferentes

Librero¹,

Peiró²,

Belda³

et al. 2014

Rev. Esp. Salud Publica

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(*) Ayuda de investigación de la Fundación Mapfre (convocatoria 2010).Conflicto de intereses: Ninguno en relación con este manuscrito. RESUMENFundamentos: el uso del "porcentaje de cesáreas" como indicador de calidad ha sido criticado por no considerar que los hospitales atienden partos con riesgos diferentes que podrían justificar su variabilidad. El objetivo de este trabajo es explorar las características de un indicador restringido al porcentaje de cesáreas en partos de bajo riesgo.Métodos: cohorte retrospectiva de todos los partos atendidos en hospitales públicos de la Comunidad Valenciana durante el periodo 2005-2010 (n=214.611; fuente: Conjunto mínimo de datos básicos), en la que se identificaron los partos de bajo riesgo (edad menor 35 años, sin antecedentes de cesárea, duración de lasgestación entre 37-41 semanas, y feto único, presentación cefálica y normopeso. Se analizó la variabilidad en el indicador, su correlación con el indicador bruto y, mediante modelos de regresión logística multinivel, la presencia de riesgos remanentes.Resultados: un total de 117.589 (58,4% del total) partos fueron identificados como de bajo riesgo. El porcentaje de cesáreas en este subgrupo fue del 11,9% (24,4% para el total) con un rango entre hospitales del 7,0% al 28,9%. El porcentaje de cesáreas en bajo riesgo y total se correlacionaron fuertemente (r=0,88). El ajuste de los riesgos remanentes en la población de bajo riesgo no alteró el efecto hospital sobre el porcentaje de cesáreas.Conclusiones: el porcentaje de cesáreas en partos de bajo riesgo incluye un alto volumen de partos, correlaciona con el indicador bruto y los riesgos remanentes no están influidos diferencialmente por los hospitales, siendo útil para monitorizar la calidad de la atención obstétrica en el Sistema Nacional de Salud.Palabras clave: Cesárea. Calidad asistencial. Ajuste de riesgos.

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“…i dag ikke en omforent metode for å vurdere når variasjonen i rater er så stor at man kan fastslå at det er systematisk, det vil si reell variasjon (Ibáñez et al, 2009 …”

Section: Tolkning Av Resultateneunclassified

Behandling av håndleddsbrudd 2009 – 14

Kvernmo¹,

Otterdal²,

Balteskard³

2017

Tidsskriftet

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Is there much variation in variation? Revisiting statistics of small area variation in health services research

Cited by 68 publications

References 27 publications

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Porcentaje de cesáreas en mujeres de bajo riesgo: un indicador útil para comparar hospitales que atienden partos con riesgos diferentes

Behandling av håndleddsbrudd 2009 – 14

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