Reducing unwarranted variability in care

Inconsistent care practices adversely affect outcomes, patient safety, performance measures and cost. Care teams rely on advanced clinical practices to reduce care variability and ensure they’re providing clinically effective care.

Clinical healthcare variation has been a topic of discussion and analysis since the early 1970s, when studies started highlighting geographic differences in cost and outcomes. Despite the widespread acknowledgement of care variations, current studies still report these inconsistencies, with costs estimated at between 14-16% of total healthcare spend in the United States. What has changed in the intervening 40 years? We now have the know-how, technology, and the sense of urgency to reduce variability and work toward standardization of care.

So, if the evidence of waste is proven, and we have the knowledge to address it, why haven’t we made further strides to achieve clinical effectiveness?

Clinical variations in focus

In the years since that first report, clinical research has identified both the causes and costs of care variations, along with potential health solutions that can improve quality and eliminate clinical waste. A pivotal piece of research, Eliminating Waste in US Health Care, by Donald M. Berwick, MD, MPP and Andrew D. Hackbarth, MPhil, revealed that waste in clinical care occurs when: (1) patients fall through the cracks in a fragmented system; (2) they are subjected to care that, according to evidence and the patients' own preferences, cannot help them; and (3) the clinical choices that patients and providers sometimes make aren't justified by available knowledge and experience.

In fact, unproven treatments amount to trillions of dollars globally, stretching health systems already strained beyond their limits. Although it’s been widely accepted that evidence-based care is crucial, it’s equally important that healthcare organizations make required changes systemically – that is, across care teams and care settings – in order to change deeply-rooted behaviors. Not only among the clinical staff, but among patients themselves who have a role to play in understanding their care choices.

Did you know?

• Hospital admissions rates are twice as high in Australia, Germany, and Israel than in Canada, Portugal and Spain. They also vary by two-fold or more across geographic areas of a country.
• Knee replacement rates are up to four times higher in Australia, Switzerland, Finland, Canada and Germany than in Israel. They also vary across geographic areas of a same country, often by two- to-three folds and up to five-fold across Canadian regions. These variations are influenced by physicians’ practice styles and socio-economic characteristics of the population.
• The probability of giving birth by c-section is 50% higher in Italy, Portugal, Australia, Switzerland and Germany than in Finland, even after adjustment by the age of the mother. Variations in c-section rates are particularly large across Italian provinces (up to six-fold). C-section rates are higher in private settings and for women with higher economic status.
• Cardiac procedures vary by more than three-fold across countries and have the highest level of variation for more than half of the OECD 35 member countries, which span North and South America, Europe, and Asia-Pacific. They are particularly high for coronary bypass in Spain and Portugal. Revascularisation procedures are lower among people living in regions with low density, low level of education and low-income.
• The prevalence of hysterectomy is 75% higher in Canada and Germany (350 per 100,000 females) than in Israel, Spain, Portugal or the Czech Republic (less than 200 per 100,000 females). Most countries have two- to three-fold variation across geographic areas, but the variation is around four-fold in Canada and the Czech Republic. Hysterectomy is more frequent in women with low- economic status, especially when physicians have greater discretion.