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Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L. Addressing unwarranted clinical variation: A rapid review of current evidence. J Eval Clin Pract 2019; 25:53-65. [PMID: 29766616 DOI: 10.1111/jep.12930] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness. DESIGN Rapid evidence assessment (REA) methodology was used. DATA SOURCES A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature. DATA SYNTHESIS Results were merged using reference-management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature. RESULTS A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV. CONCLUSION Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically explore and address UCV. The instances of UCV that warrant investigation and action are largely determined at a systems level currently, and stakeholder engagement in this process is limited. Lack of consensus on an evidence-based definition for UCV remains a substantial barrier to progress in this field.
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Affiliation(s)
- Reema Harrison
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Elizabeth Manias
- Melbourne School of Health Sciences, The University of Melbourne and Research Professor, School of Nursing and Midwifery, Deakin University, Australia
| | - Stephen Mears
- Hunter New England Medical Library, New Lambton, Australia
| | - David Heslop
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Reece Hinchcliff
- University of Technology Sydney, Centre for Health Services Research, Ultimo, Australia
| | - Liz Hay
- Economics and Analyticss, Strategic Reform Branch, NSW Ministry of Health, North Sydney, Australia
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Ramanathan SA, Hibbert PD, Maher CG, Day RO, Hindmarsh DM, Hooper TD, Hannaford NA, Runciman WB. CareTrack: Toward Appropriate Care for Low Back Pain. Spine (Phila Pa 1976) 2017; 42:E802-E809. [PMID: 27831965 DOI: 10.1097/brs.0000000000001972] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective medical record review to assess compliance with low back pain (LBP) care indicators. OBJECTIVE To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings. SUMMARY OF BACKGROUND DATA LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings. METHODS A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators ("CareTrack"). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010. RESULTS Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%-98%). Allied health practitioners and hospitals were the most compliant (82%-83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction. CONCLUSION Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified. LEVEL OF EVIDENCE N /A.
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Affiliation(s)
- Shanthi A Ramanathan
- Hunter Medical Research Institute and University of Newcastle, Newcastle, Australia.,University of South Australia, Adelaide, Australia.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Peter D Hibbert
- University of South Australia, Adelaide, Australia.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard O Day
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,Clinical Pharmacology and St Vincent's Clinical School, St Vincent's Hospital and University of New South Wales, Sydney, NSW, Australia
| | - Diane M Hindmarsh
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | | | - William B Runciman
- University of South Australia, Adelaide, Australia.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,Australian Patient Safety Foundation, Adelaide, Australia
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Hibbert PD, Hannaford NA, Hooper TD, Hindmarsh DM, Braithwaite J, Ramanathan SA, Wickham N, Runciman WB. Assessing the appropriateness of prevention and management of venous thromboembolism in Australia: a cross-sectional study. BMJ Open 2016; 6:e008618. [PMID: 26962033 PMCID: PMC4785294 DOI: 10.1136/bmjopen-2015-008618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 01/14/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The prevention and management of venous thromboembolism (VTE) is often at variance with guidelines. The CareTrack Australia (CTA) study reported that appropriate care (in line with evidence-based or consensus-based guidelines) is being provided for VTE at just over half of eligible encounters. The aim of this paper is to present and discuss the detailed CTA findings for VTE as a baseline for compliance with guidelines at a population level. SETTING The setting was 27 hospitals in 2 states of Australia. PARTICIPANTS A sample of participants designed to be representative of the Australian population was recruited. Participants who had been admitted overnight during 2009 and/or 2010 were eligible. Of the 1154 CTA participants, 481(42%) were admitted overnight to hospital at least once, comprising 751 admissions. There were 279 females (58%), and the mean age was 64 years. PRIMARY AND SECONDARY OUTCOME MEASURES The primary measure was compliance with indicators of appropriate care for VTE. The indicators were extracted from Australian VTE clinical practice guidelines and ratified by experts. Participants' medical records from 2009 to 2010 were analysed for compliance with 38 VTE indicators. RESULTS Of the 35,145 CTA encounters, 1078 (3%) were eligible for scoring against VTE indicators. There were 2-84 eligible encounters per indicator at 27 hospitals. Overall compliance with indicators for VTE was 51%, and ranged from 34% to 64% for aggregated sets of indicators. CONCLUSIONS The prevention and management of VTE was appropriate for only half of the at-risk patients in our sample; this provides a baseline for tracking progress nationally. There is a need for national and, ideally, international agreement on clinical standards, indicators and tools to guide, document and monitor care for VTE, and for measures to increase their uptake, particularly where deficiencies have been identified.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Natalie A Hannaford
- Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
- Australian Patient Safety Foundation, Adelaide, South Australia, Australia
| | - Tamara D Hooper
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Diane M Hindmarsh
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Shanthi A Ramanathan
- Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
- Hunter Valley Research Foundation, Newcastle, New South Wales, Australia
| | - Nicholas Wickham
- Adelaide Cancer Centre, Kurralta Park, South Australia, Australia
| | - William B Runciman
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
- Australian Patient Safety Foundation, Adelaide, South Australia, Australia
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Hooper TD, Hibbert PD, Hannaford NA, Jackson N, Hindmarsh DM, Gordon DL, Coiera EC, Runciman WB. Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis. Anaesth Intensive Care 2015; 43:461-7. [PMID: 26099757 DOI: 10.1177/0310057x1504300407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.
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Affiliation(s)
- T D Hooper
- Project Manager, Centre for Sleep Research, University of South Australia, Adelaide, South Australia
| | - P D Hibbert
- Program Manager, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales
| | - N A Hannaford
- Senior Analyst, Clinical Research, Centre for Sleep Research, University of South Australia, Adelaide, South Australia
| | - N Jackson
- Research Assistant, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales
| | - D M Hindmarsh
- Biostatistician, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales
| | - D L Gordon
- Professor, Microbiology and Infectious Diseases, SA Pathology, Flinders Medical Centre, Bedford Park, South Australia
| | - E C Coiera
- Professor, Chief Investigator, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales
| | - W B Runciman
- Chief Investigator, Centre for Sleep Research, University of South Australia, Adelaide, South Australia
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Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA, Braithwaite J. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012. [DOI: 10.5694/mja12.11210] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Peter D Hibbert
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Enrico W Coiera
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | - Richard O Day
- St Vincent's Clinical School and School of Medical Sciences, University of New South Wales, Sydney, NSW
| | - Diane M Hindmarsh
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
| | | | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW
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