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 differences1; it is due to non–evidence-based, inappropriate, and/or inefficient health care. Unwarranted variation in pediatrics has been demonstrated since the early 1900s, when Sir Allison Glover2 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 over-crowding, 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 …

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