Unwarranted variation

Last updated

Unwarranted variation (or geographic variation) in health care service delivery refers to medical practice pattern variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine. It is one of the causes of low value care often ignored by health systems. [1]

Contents

Definition

Unwarranted variation (or geographic variation) in health care service delivery refers to differences that cannot be explained by personal preference, illness, medical need, or the dictates of evidence-based medicine. The term was coined by Dr. John Wennberg. [2] Unwarranted variation reveals three areas:

Supply-sensitive care, which is strongly correlated with healthcare system resource capacity and generally provided in the absence of medical evidence and clinical theory. It also drives inequity as those from poorer backgrounds are often less profitable, or have more complex needs. [5]

History

In 1938, in the Journal of the Royal Society of Medicine, J. Alison Glover published a paper showing unexplained variations in tonsillectomy rates across British school districts. [6] In 1967, John (Jack) Wennberg analyzed Medicare data to determine how well hospitals and doctors were serving their communities. He found four types of variation: the underuse of effective care, variations in outcomes attributable to the quality of care, the misuse of preference-sensitive treatments and overuse of supply-sensitive services. [7]

According to Health Dialog, a privately held, for-profit disease-management company which was established to address unwarranted variation:

If you live in northern Idaho, and you develop back pain, chances are good that you'll undergo surgery to treat your pain. Move to the southern tip of Texas, however, and the chances that you'll undergo that same surgery will drop by a factor of 6. The surgery is no more effective in Idaho than it is in Texas. It's just that doctors in the northwest are more likely than those in southern Texas to recommend surgery. This phenomenon, in which doctors practice medicine differently depending on where they're from, is called practice pattern variation. And it isn't limited to treating back pain, or even surgical decisions. There is also variation in treatment for chronic conditions, such as use of beta blockers for individuals with Congestive Heart Failure (CHF) or lipid testing for those with diabetes. [8] [ full citation needed ]

Wennberg and colleagues at the Dartmouth Center for Evaluative Clinical Sciences documented these wide variations in how healthcare is practiced around the United States. They have asserted that most of this variation is unwarranted. Health Dialog was built to address unwarranted variation in healthcare: the overuse, underuse and misuse of medical care. Wennberg and his colleagues concluded that if unwarranted variation in the US healthcare system could be reduced, the quality of care would go up and healthcare costs would go down. Studies have shown that if unwarranted variation could be reduced in the Medicare population, quality of care would rise dramatically and costs could be lowered by as much as 30%. [9]

Extent

Unwarranted variation in medical practice is costly and deadly as noted by Martin Sipkoff in 9 Ways To Reduce Unwarranted Variation. Analysis of Medicare data revealed that per-capita spending per enrollee in Miami was almost 2.5 times as much as in Minneapolis, even after adjusting data for age, sex, and race. According to a 2003 report from the National Committee for Quality Assurance, 57,000 people died annually because US physicians have not been using evidence-based medicine to guide their care. [10]

"We're literally dying, waiting for the practice of medicine to catch up with medical knowledge," said Margaret O'Kane, president of the National Committee for Quality Assurance (NCQA). The report, "The State of Health Care Quality 2003," says that the deaths "should not be confused with those attributable to medical errors or lack of access to health care. This report shows that a thousand Americans die each week because the care they get is not consistent with the care that medical science tells us they should get." [10]

United States

Studies show that individuals with diabetes should have blood lipids monitored regularly, yet patients in Chicago are 50% less likely to receive these tests than patients in Fort Lauderdale. A patient with heart disease in Bloomington, Indiana, is three times more likely to have bypass surgery than a similar patient in Albuquerque. In Miami, where medical services are abundant, Medicare pays more than twice as much per person per year as it does in Minneapolis, with no discernible difference in overall health or life expectancy. [8] [ page needed ]

NHS England

In November 2010 the Department of Health QIPP Right Care programme published the first NHS Atlas of Variation in Healthcare, inspired by the work of Wennberg. [11] Clinicians selected 34 topics, as being important to their speciality, which were mapped by primary care trust area, then the healthcare commissioning body. The Atlas was published to challenge commissioners to maximise health outcome and minimise inequalities by addressing unwarranted variation:

"Awareness is the first important step in identifying and addressing unwarranted variation; if the existence of variation is unknown, the debate about whether it is unwarranted cannot take place." [12] : 15 

The 2010 atlas revealed widespread variations in outcome, quality, cost and activity:

A further extended Atlas was published in November 2011, mapping variation across 71 indicators [13] and a follow-on series of Atlases focussing on specific themes in more depth like children and young people, diabetes, kidney disease and respiratory disease. Other Atlases focus on topics such as liver disease, diagnostics, organ donation and transplantation. [14] Publication of the atlases has been well-received within the NHS and by patient groups and clinical societies as well as by healthcare systems in other countries. [15] [16]

In 2012, the Department of Health published a mandate for the new NHS Commissioning Board. On variation in healthcare, the mandate charged the board with the responsibility to "shine a light on variation" and "to make significant progress... in reducing unjustified variation... Success will be measured not only by the average level of improvement but also by progress in reducing health inequalities and unjustified variation." [17] : 7, 13, 27 

COVID-19 rates were found to be associated with unwarranted variations too. In a study published in 2022 in British Journal of Healthcare Management, [18] a significant association between long unemployment and likelihood of death from COVID-19 was found in England. Areas with higher proportions of individuals from Black, Asian and ethnic minority backgrounds were also more likely to have higher rates of hospitalisations and deaths from COVID-19.

Nursing, midwifery and care staff framework, England

In April 2016, Jane Cummings, Chief Nursing Officer (CNO) for England, launched a national strategic framework for nurses, midwives and care staff in England called Leading Change, Adding Value. [19] This framework sets out the 10 commitments for nurses, midwives and care staff in England towards identifying and addressing unwarranted variation in care practice. The framework builds on the previous CNO strategy 'Compassion in Practice' [20] and identifies the nursing, midwifery and care staff approach to meeting the triple aims of 'improving health outcomes, reducing the care quality gap and effective use of resources' as set out in the Department of Health's Five Year Forward View. [21] Actions to address unwarranted variation in nursing, midwifery and care provision are underpinned by the values of the 6Cs of Nursing [22] and a skills and knowledge framework is being developed to support staff in delivering on the 10 commitments set out in the framework.

See also

Related Research Articles

Health care reform is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:

A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care provider.

<span class="mw-page-title-main">Family medicine</span> Medical specialty

Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.

Polyclinics in England were intended to offer a greater range of services than were offered by current general practitioner (GP) practices and local health centres. In addition to traditional GP services they would offer extended urgent care, healthy living services, community mental health services and social care, whilst being more accessible and less medicalised than hospitals. A variety of models were proposed, ranging from networks of existing clinics to larger premises with several colocated general practitioner (GP) practices, more extensive facilities and additional services provided by allied healthcare professionals.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

<span class="mw-page-title-main">Ara Darzi, Baron Darzi of Denham</span> Armenian-British surgeon (born 1960)

Ara Warkes Darzi, Baron Darzi of Denham, is an Armenian-British surgeon, academic, and politician.

John E. "Jack" Wennberg is the pioneer and leading researcher of unwarranted variation in the healthcare industry. In four decades of work, Wennberg has documented the geographic variation in the healthcare that patients receive in the United States. In 1988, he founded the Center for the Evaluative Clinical Sciences at Dartmouth Medical School to address that unwarranted variation in healthcare.

Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.

In economics, supplier induced demand (SID) may occur when asymmetry of information exists between supplier and consumer. The supplier can use superior information to encourage an individual to demand a greater quantity of the good or service they supply than the Pareto efficient level, should asymmetric information not exist. The result of this is a welfare loss.

The Dartmouth Institute for Health Policy and Clinical Practice (TDI) is an organization within Dartmouth College "dedicated to improving healthcare through education, research, policy reform, leadership improvement, and communication with patients and the public." It was founded in 1988 by John Wennberg as the Center for the Evaluative Clinical Sciences (CECS); a reorganization in 2007 led to TDI's current structure.

Outcomes research is a branch of public health research which studies the end results of the structure and processes of the health care system on the health and well-being of patients and populations. According to one medical outcomes and guidelines source book - 1996, Outcomes research includes health services research that focuses on identifying variations in medical procedures and associated health outcomes. Though listed as a synonym for the National Library of Medicine MeSH term "Outcome Assessment ", outcomes research may refer to both health services research and healthcare outcomes assessment, which aims at Health technology assessment, decision making, and policy analysis through systematic evaluation of quality of care, access, and effectiveness.

Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to patients and help them choose the treatment option that best aligns with their preferences as well as their unique cultural and personal beliefs.

<span class="mw-page-title-main">Anne Marie Rafferty</span> British nurse

Dame Anne Marie Rafferty FRCN is a British nurse, academic and researcher. She is professor of nursing policy and former dean of the Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care at King's College London. She served as President of the Royal College of Nursing from 2019 to 2021.

Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. A discipline-specific process may be referenced accordingly.

Unnecessary health care is health care provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending in 2012.

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

Choosing Wisely Canada (CWC) is a Canadian-based health education campaign launched on April 2, 2014 under the leadership of Wendy Levinson, in partnership with the Canadian Medical Association, and based at Unity Health Toronto and the University of Toronto. The campaign aims to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to assist physicians and patients in making informed and effective choices to ensure high quality care.

Elliott S. Fisher is a health policy researcher and advocate for improving health system performance in the United States. He helped develop the concept of accountable care organizations and championed their adoption by Medicare. The development of the Affordable Care Act was influenced by his research on disparities in healthcare spending and utilization across the United States. He has strongly supported a rapid transition from fee-for-service to pay-for-performance models in the U.S. healthcare industry. He is a tenured faculty member at Dartmouth College, where he teaches in the Masters in Public Health program.

References

  1. ↑ Gray, Muir (2017-01-27). "Value based healthcare". BMJ. 356: j437. doi:10.1136/bmj.j437. ISSN   0959-8138. PMID   28130219. S2CID   28359407.
  2. ↑ Wennberg, John E. (2011-03-17). "Time to tackle unwarranted variations in practice". BMJ. 342: d1513. doi:10.1136/bmj.d1513. ISSN   0959-8138. PMID   21415111. S2CID   3579110.
  3. ↑ Berwick, Donald M. (2017-07-08). "Avoiding overuse—the next quality frontier". The Lancet. 390 (10090): 102–104. doi:10.1016/S0140-6736(16)32570-3. ISSN   0140-6736. PMID   28077229. S2CID   20215238.
  4. ↑ Korenstein, Deborah; Chalmers, Kelsey; Srivastava, Divya; Saini, Vikas; Nagpal, Somil; Heath, Iona; Glasziou, Paul; Elshaug, Adam G.; Doust, Jenny (2017-07-08). "Evidence for overuse of medical services around the world". The Lancet. 390 (10090): 156–168. doi:10.1016/S0140-6736(16)32585-5. ISSN   0140-6736. PMC   5708862 . PMID   28077234.
  5. ↑ Unwarranted Variation Health Dialog, healthdialog.com Archived December 11, 2007, at the Wayback Machine
  6. ↑ Wennberg, John (2008-02-01). "Commentary: A debt of gratitude to J. Alison Glover". International Journal of Epidemiology. 37 (1): 26–29. doi: 10.1093/ije/dym262 . ISSN   0300-5771. PMID   18245049.
  7. ↑ McCue, Michael T. (February 1, 2003). "Clamping down on variation". Managed Healthcare Executive. Archived from the original on December 18, 2007.
  8. 1 2 The Dartmouth Atlas of Healthcare, 1999.
  9. ↑ Fisher E.S., Wennberg D.E., Stukel T.A., et al. The implications of regional variations in Medicare spending. Part 1. Ann Intern Med. 2003; 138: 273-287.
  10. 1 2 Sipkoff, Martin (November 2003). "9 Ways To Reduce Unwarranted Variation". Managed Care Magazine. Archived from the original on December 5, 2003.{{cite magazine}}: CS1 maint: unfit URL (link)
  11. ↑ The NHS Atlas of Variation in Healthcare (PDF) (Report). November 2010. Retrieved September 30, 2023.
  12. ↑ The NHS Atlas of Variation in Healthcare Archived 2012-12-08 at the Wayback Machine NHS, 2010
  13. ↑ The NHS Atlas of Variation in Healthcare (PDF) (Report). November 2011. Retrieved September 30, 2023.
  14. ↑ "Atlas of Variation". Office for Health Improvement & Disparities. Retrieved 2023-09-30.
  15. ↑ Hauge Pedersen, Marie; Breinholt Larsen, Finn (25 November 2015). Læring fra det engelske sundhedsvæsens arbejde med NHS Atlas of Variation in Healthcare. Forbrugsvariationsprojektet – Delprojekt 4 (Report) (in Danish). Folkesundhed og Kvalitetsudvikling, Koncern Kvalitet, Region Midtjylland. ISBN   978-87-92400-71-0.
  16. ↑ DaSilva, Philip; Gray, J. A. Muir (November 2016). "English lessons: can publishing an atlas of variation stimulate the discussion on appropriateness of care?" (PDF). Medical Journal of Australia . 205 (S10). doi:10.5694/mja15.00896. ISSN   0025-729X.
  17. ↑ The Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 (PDF) (Report). Department of Health. November 2013.
  18. ↑ Gharaibeh, Sara Abdul-Karim Qasim; Zarei, Mohammad Hossein (2022-04-02). "Socioeconomic variations in rates of hospitalisation and mortality from COVID-19 in England". British Journal of Healthcare Management. 28 (4): 1–8. doi:10.12968/bjhc.2022.0001. ISSN   1358-0574. S2CID   248192621.
  19. ↑ Nursing framework NHS May 2016
  20. ↑ Compassion in practice NHS December 2012
  21. ↑ Five year forward view NHS October 2014
  22. ↑ "What are the 6C's of Nursing?". NursingNotes. 2015-11-05. Retrieved 2021-05-22.

News publications

Academic publications

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.