Using Quality Improvement to Tackle Unwarranted Practice Variation

Abstract

As health care in the United States moves from quantity to quality, unwarranted practice variation has become a natural target for those wishing to improve care. Variation in provider practice should arise from personalizing care decisions on the basis of each patient' s condition and personal preferences. ''Unwarranted'' variation refers to variation beyond what would be expected based on patient or population differences 1 ; it is due to non-evidencebased, inappropriate, and/or inefficient health care. Unwarranted variation in pediatrics has been demonstrated since the early 1900s, when Sir Allison Glover 2 compared pediatric tonsillectomy rates in geographically and demographically similar areas of England. He showed a .10-fold variation in rates and concluded, "A study of the geographical distribution [of tonsillectomy] in children discloses no correlation between any other factor, such as overcrowding , poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications." 2 Despite broad dissemination of evidence-based guidelines for asthma management, 3 unwarranted variation persists in care and outcomes for children treated in emergency departments and/or hospitalized for asthma. Studies have demonstrated wide variation in rates of diagnostic testing (eg, complete blood counts), interventions (eg, intravenous [IV] magnesium sulfate), transfer to ICUs, hospital readmissions, length of stay, and costs, even after correction for patient characteristics. 4-7 This variation is largely due to the challenges of integrating guidelines into care, which may take up to 17 years. 8

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions

“…Additionally, we found no significant associations between HOSSP adherence and LOS or 7‐day all‐cause readmissions 24 . Our findings suggest that standardizing the approach to care for routine pediatric hospital conditions may decrease the cost of care without worsening clinical outcomes 25 …”

“…24 Our findings suggest that standardizing the approach to care for routine pediatric hospital conditions may decrease the cost of care without worsening clinical outcomes. 25 An additional strength of the HOSSP as an empiric hospitalspecific measure of variation is its ability to better characterize drivers of variation by examining laboratory, imaging, and medication practices across conditions and sites. The variability we detected through use of the HOSSP broadly fell into two types: (1) variability from overuse and over testing, and (2) variability secondary to lack of evidence to direct best care.…”

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children’s Hospitals

“…Given the importance of detecting occult intracranial injuries, complexity of the decision to perform neuroimaging, and lack of clear practice guidelines, overassessment and underassessment may be occurring. If evidence of excess variation in neuroimaging practices when abuse is suspected were found, this would support the need for quality and safety improvement . Furthermore, there are known racial and ethnic and socioeconomic disparities in use of skeletal surveys to identify clinically occult fractures, suggesting bias in considering abuse .…”

“…If evidence of excess variation in neuroimaging practices when abuse is suspected were found, this would support the need for quality and safety improvement. 8 , 9 Furthermore, there are known racial and ethnic and socioeconomic disparities in use of skeletal surveys to identify clinically occult fractures, suggesting bias in considering abuse. 10 , 11 , 12 Whether biases continue after the initial decision to evaluate with a skeletal survey is unknown, but such continuation would further support the need for standardization of care.…”

Decreasing Pain in Hospitalized Patients by Increasing Topical Anesthetic Use for Peripheral IVs

“…[23][24][25] Additionally, clinical pathways are an effective strategy to improve the delivery of evidence-based care. [26][27][28][29][30] Within our institution, topical anesthetic use before venous access procedures was minimal, and there was little consideration of emotional or behavioral support for the patient and caregiver during the procedure. Recognizing the impact of needle procedures on our hospitalized population, the global aim of our QI initiative was to reduce unnecessary pain experienced by pediatric patients during peripheral intravenous line (PIV) placement during hospitalization.…”