Regional Variation In Practice Research Articles

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register‐based study in the Netherlands

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register‐based study in the Netherlands

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis.

Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). One hundred-fifty-three ICUs in 13 countries. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). None. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Utilization of the percutaneous left ventricular support as bridge to heart transplantation across the United States: In-depth UNOS database analysis

Intra-aortic balloon pump (IABP) and Impella device utilization as a bridge to heart transplantation (HTx) have risen exponentially. We aimed to explore the influence of device selection on HTx outcomes, considering regional practice variation. A retrospective longitudinal study was performed on a United Network for Organ Sharing (UNOS) registry dataset. We included adult patients listed for HTx between Oct 2018 and April 2022 as status 2, as justified by requiring IABP or Impella support. The primary endpoint was successful bridging to HTx as status 2. Of 32,806 HTx during the study period, 4,178 met inclusion criteria (Impella n = 650, IABP n = 3,528). Waitlist mortality increased from a nadir of 16 (in 2019) to a peak of 36 (in 2022) per thousand status 2 listed patients. Impella annual use increased from 8% in 2019 to 19% in 2021. Compared to IABP, Impella patients demonstrated higher medical acuity and lower success rate of transplantation as status 2 (92.1% vs. 88.9 %, P < 0.001). The IABP: Impella utilization ratio varied widely between regions, ranging from 1.77 to 21.31, with high Impella use in Southern and Western states. However, this difference was not justified by medical acuity, regional transplant volume, or waitlist time and did not correlate with waitlist mortality. The shift in utilizing Impella as opposed to IABP did not improve waitlist outcomes. Our results suggest that clinical practice patterns beyond mere device selection determine successful bridging to HTx. There is a critical need for objective evidence to guide tMCS utilization and a paradigm shift in the UNOS allocation system to achieve equitable HTx practice across the United States.

Regional practice variation in induction of labor in the Netherlands: Does it matter? A multilevel analysis of the association between induction rates and perinatal and maternal outcomes.

Practice variation in healthcare is a complex issue. We focused on practice variation in induction of labor between maternity care networks in the Netherlands. These collaborations of hospitals and midwifery practices are jointly responsible for providing high-quality maternity care. We explored the association between induction rates and maternal and perinatal outcomes. In a retrospective population-based cohort study, we included records of 184,422 women who had a singleton, vertex birth of their first child after a gestation of at least 37 weeks in the years 2016-2018. We calculated induction rates for each maternity care network. We divided networks in induction rate categories: lowest (Q1), moderate (Q2-3) and highest quartile (Q4). We explored the association of these categories with unplanned caesarean sections, unfavorable maternal outcomes and adverse perinatal outcomes using descriptive statistics and multilevel logistic regression analysis corrected for population characteristics. The induction rate ranged from 14.3% to 41.1% (mean 24.4%, SD 5.3). Women in Q1 had fewer unplanned caesarean sections (Q1: 10.2%, Q2-3: 12.1%; Q4: 12.8%), less unfavorable maternal outcomes (Q1: 33.8%; Q2-3: 35.7%; Q4: 36.3%) and less adverse perinatal outcomes (Q1: 1.0%; Q2-3: 1.1%; Q4: 1.3%). The multilevel analysis showed a lower unplanned caesarean section rate in Q1 in comparison with reference category Q2-3 (OR 0.83; p = .009). The unplanned caesarean section rate in Q4 was similar to the reference category. No significant associations with unfavorable maternal or adverse perinatal outcomes were observed. Practice variation in labor induction is high in Dutch maternity care networks, with limited association with maternal outcomes and no association with perinatal outcomes. Networks with low induction rates had lower unplanned caesarean section rates compared to networks with moderate rates. Further in-depth research is necessary to understand the mechanisms that contribute to practice variation and the observed association with unplanned caesarean sections.

Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data

ObjectivesTo explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP).Design and settingA retrospective cohort study employing administrative health data...

Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?

Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?

Interregional practice variations in the use of local therapy for synchronous colorectal liver metastases in the Netherlands.

The aim of this study was to evaluate the Dutch regional practice variation in treatment of synchronous colorectal liver metastases (CRLM) over time and assess their impact on patients survival. Two cohorts of patients with synchronous CRLM were selected from the Netherlands Cancer Registry (NCR). All patients diagnosed between 2014 and 2018 were selected to analyze interregional practice variations in local therapy (LT) with multivariable logistic regression. Overall survival (OS) was assessed for patients diagnosed from 2008 to 2013 using Kaplan Meier method and Cox regression analyses. The proportion of patients who underwent LT increased from 15.5% to 21.9%. Interregional use of LT varied from 19.1% to 25.0%. Multivariable logistic regression showed significant differences between regions in the use of LT (p=0.001) in 2014-2018. There was no association between OS and region of diagnosis for patients who underwent LT after correction for confounders.The use of LT for CRLM increased from 15.5% in 2008-2013 to 21.9% in 2014-2018. Three-year OS increased from 16% to 19% respectively. Interregional practice variations have decreased. The remaining differences are not associated with OS. The use of local therapy and 3-year overall survival have increased over time. Local practice should be monitored to prevent undesirable variation in outcomes.

Regional Practice Variation and Its Impact on Reoperation After Revascularization for Acute Limb Ischemia Versus Peripheral Arterial Disease

We queried our statewide All-Payers Database to identify patients with acute limb ischemia (ALI) and peripheral arterial disease (PAD) and identified the impact of treatment setting, antithrombotic prescribing practice patterns, and operative approach on ALI vs PAD outcomes.

Adapting a National Framework to Inform Curricular Redesign Focused on Enhancing Student Clinical Competency

Doctor of Pharmacy (PharmD) programs continually engage in curricular redesign to ensure practice readiness of graduates. With ever-increasing demands on clinical competency and curricular time, it is important to be intentional when determining curricular priorities and prioritize contemporary pharmacist practice. This paper describes how to adapt a national framework for pharmacotherapy curricula to emphasize the pharmacist’s role within a given topic area in order to facilitate conversations about allotting curricular time during a curricular redesign. Customized Tier descriptions based on various factors expected of student pharmacists during Advanced Pharmacy Practice Experiences (APPEs) were developed (e.g., relative autonomy of the pharmacist in managing the topic, emphasis on licensing exams, frequency with which students can expect to encounter the topic at school-specific experiential placements, and condition-specific information). Topics were also reprioritized to address regional variations in practice and ideologies. Customizing a national framework to determine program-specific considerations for prioritizing topics within the pre-APPE curriculum can help faculty and students alike maintain focus on highly critical and foundational concepts, while also making sure not to completely disregard topics of lower priority. We have proposed such a framework for programs to utilize when facilitating conversations surrounding curricular reforms and topic prioritization.

Emergency airway management in a Singapore centre: A registry study

Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.

Regional and practitioner variations in reporting infant mortality

Objective Assess regional differences in categorization of preterm delivery outcomes and impact on variation in reported infant mortality rates. Study design A 27-item questionnaire was distributed to 1072 practitioners associated with U.S. birth hospitals. Five clinical scenarios were created to identify how participants classify delivery outcomes. Statistical analysis included Chi-square analysis and multinomial logistic regression. Results 234 questionnaires were completed (response rate 22%). While >90% respondents classified a 14-week pregnancy loss with no sign of life as a miscarriage, only 22% would provide a fetal death certificate. Likewise, 37% would provide a certificate of live birth for a loss at 16 weeks with signs of life. There was notable regional variation in classifying these as live births (Northeast: 41%, Midwest: 44%, South: 13%, and West: 18%, p = .003). Conclusion Regional practice variation in recording both live births and stillbirths was noted. Greater standardization in reporting practices may be warranted to improve the accuracy of reported birth outcomes in the U.S.

Practice variation in long-term care access and use: The role of the ability to pay.

ABSTRACTPractice variation in publicly financed long‐term care (LTC) may be inefficient and inequitable, similarly to practice variation in the health care sector. Although most OECD countries spend an increasing share of their gross domestic product on LTC, it has received comparatively little attention to date compared with the health care sector. This paper contributes to the literature by assessing and comparing regional practice variation in both access to and use of institutional LTC and investigating its relation with income and out‐of‐pocket payment. For this, we have access to unique individual‐level data covering the entire Dutch population. Even though we found practice variation in the use of LTC once access was granted, the variation between regions was still relatively small compared with international standards. In addition, we showed how a co‐payment measure could be used to reduce practice variation across care office regions and income classes making the LTC system not only more efficient but also more equitable.

Investigating the Impact of Geographic Location on Colorectal Cancer Stage at Diagnosis: A National Study of the SEER Cancer Registry.

Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents. Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics. In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis. Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.

Kidney Cancer Research Network of Canada (KCRNC) consensus statement on the role of renal mass biopsy in the management of kidney cancer.

The pervasive use of diagnostic imaging has led to an increase in the incidental detection of small renal masses.1–4 The assessment and management of a patient with a renal mass should vary based on mass characteristics and on the individual patient’s health and personal preferences. Renal mass biopsy is a diagnostic test used to obtain tissue from a suspicious mass in the kidney. Several patient factors and mass characteristics should be considered to determine when a biopsy is a useful test for a patient. Recently, there have been a number of published series on renal mass biopsy that discuss which patient populations benefit from this diagnostic test.5–7 The objectives of this consensus statement are: 1) to review and synthesize the evidence on renal mass biopsy; and 2) to highlight important concepts and provide guidance regarding the role of renal mass biopsy. The statements contained in this report were based on the best available evidence and developed by expert consensus. It is expected that these statements will be used to guide care in Canada and that some variability in practice will exist for individual patients and regional practice variation. The scientific literature available for this consensus statement was of low-to-moderate-quality. The evidence reported on renal mass biopsy is predominantly comprised of retrospective cohort series of patients managed at high-volume centers.5–7 Recently, a systematic review and meta-analysis of renal mass biopsy was published, which summarizes the best available evidence on the diagnostic ability and safety of this test.7

Navigating the Murk: Ethical and Practical Considerations for the Surgical Treatment of the Sacroiliac Joint Syndrome

The field of spine surgery has many controversies. The surgical treatment of the sacroiliac (SI) joint is, too, fraught with debate. The diagnosis of painful SI joints is currently limited to relief following “diagnostic” injections and pain generated from a suite of clinical maneuvers. Diagnoses of SI joint dysfunction are dependent entirely on patient-reported responses to provocative maneuvers and invasive procedures. There is a glaring lack of objective radiographic and objective physical examination findings for this syndrome. The evidence for treatment, and specifically for the surgical treatment of the SI joint is reviewed and critiqued. Although the surgical techniques are simple, consensus is elusive for both indication and optimal technique. Ethical principles for surgical innovation and practical considerations for the treatment of the SI joint syndrome are discussed at length. Discussed as well are key points to consider when providing informed consent to a patient before proceeding with surgical intervention for this procedure and diagnosis. Spine surgery is a field with considerable regional variation in practice. Even today, the precise indications for arthrodesis, extent, and approach, remain frequently debated; however, as much conversation takes place surrounding lumbar surgery, even more confusion, bias, opinion, and deliberation exists when surgical treatment of the SI joint is considered. This chapter discusses the unique challenges associated with the SI joint and provides practical considerations for the treatment thereof.

Post-mastectomy radiation in node-positive breast cancer in Ontario.

More recent guidelines are more supportive for post-mastectomy radiation in all node-positive breast cancer patients. We examined the rate and predictors of post-mastectomy radiation receipt in Ontario Canada from 2010 to 2014. Of 6535 node-positive post-mastectomy patients, 73.9% received radiation. The rate was 68.7% (2903/4227) among women with 1-3 positive nodes. Radiation was less likely to be administered to women who were older, had high levels of comorbidity, or presented with early stages of breast cancer. Regional practice variation was reassuringly modest.

Route of hysterectomy: a retrospective, cohort study in English NHS Hospitals from 2011 to 2017.

To assess variation in the route of hysterectomy over 7 years and to assess regional variation in practice. Retrospective cohort study. English NHS Hospitals 2011-2017. 230 876 patients having a hysterectomy for six diagnostic categories (endometrial cancer, endometriosis and pain, menstrual disorders, fibroids, benign adnexal masses, and 'other') identified from Hospital Episode Statistics. The proportion of hysterectomies carried out by each route was calculated for each year overall and for each primary diagnosis by year. Comparisons between 2011 and 2017 were via chi-square test. Rank correlation coefficients were calculated to assess trends over the study period. Analysis of regional variation in practice was restricted to 2017. A multivariable logistic regression was performed to obtain crude and adjusted odds of having a minimal access hysterectomy. The proportion of abdominal, vaginal, laparoscopic, and failed laparoscopic procedures for each primary diagnosis by study year. Odds of a minimal access hysterectomy in 2017. The proportion of hysterectomies performed laparoscopically increased from 20.2% in 2011 to 47.2% in 2017, as did the proportion of failed laparoscopic procedures; 1.7% in 2011 to 2.8% in 2017. The proportion of abdominal hysterectomies decreased from 70.4% in 2011 to 46.5% in 2017. There was a smaller decrease in vaginal procedures from 7.8% in 2011 to 3.5% in 2017. Regional variation in the route of hysterectomy was demonstrated in 2017, which persisted when adjusted for confounding factors. The proportion of laparoscopic procedures has increased, and it was the commonest route of hysterectomy for this cohort in 2017. There were significant regional differences in route of hysterectomy in 2017. Increasing laparoscopic hysterectomy and decreasing abdominal hysterectomy rates from 2011 to 2017 with regional variation in practice.

Ландратура Санкт-Петербургской губернии: штат, функции, место в системе управления (mатериалы к исследованию)

The article focuses on the institution of the landrat, i.e. one of the lower levels of local self-government in Russia which briefly functioned in the country following the administrative reform of Peter I. Its inclusion in the Tsar’s design was motivated by the institution of the same name which had functioned in the Baltic provinces of Sweden, ceded to Russia after the Great Northern War. The introduction of the landrat into a purely Russian system of local government was done against the backdrop of a contradictory and normatively uncertain legal order and was sensitive to regional variation in practice. The author seeks to reconstruct the institution of the landrat in the Saint Petersburg governorate on the basis of a document he uncovered, the “Register of landrat officials and commissars of the Saint Petersburg governorate” of 1717, and from incomplete information available in several extant documents and published sources. The article offers a general assessment of the role and position of the landrat in the administrative structure of Russia during the reign of Peter I, and an attempt to collate the similarities and differences in the organisation of the Saint Petersburg and Siberia governorates. The article provides preliminary generalisations on the available material, expected to serve as a basis for a monograph on the history of the landrat in Russia more generally.

Regional variation in the costs of treating curative gastric cancer.

165 Background: Gastric cancer is a highly morbid and fatal disease. While the clinical challenge with gastric cancer is widely described, little is known about the economic burden of the disease. Many guidelines outline the curative treatment for gastric cancer and in a universal healthcare system, equal access and uniform healthcare delivery is predicted. Yet, regional variation in practice exists and may result in increased healthcare costs. We therefore aimed to investigate of the costs of treating curative gastric cancer, explore regional variation in costs, and to identify the factors which drive these costs. Methods: We conducted a patient-level cost analysis of curative-intent stage I-III gastric cancer diagnosed between 2005 and 2008 from the perspective of a universal healthcare system, using a 26-month time horizon. Clinical and stage data were abstracted from a provincial chart review. Costs associated with physician billings, same day surgery, hospitalization, drug benefits, emergency department visits, continuing care, and long-term care were derived using administrative healthcare databases and compared among healthcare regions. Costs were inflated to 2017 United States dollars (USD). We used a linear regression model to identify factors predictive of these treatment costs. Results: A total of 722 patients with Stage I-III gastric cancer were identified. Mean costs per region ranged from $55,650 to $92,852 (USD) across 14 health regions. The lowest contributing cost sector was long-term care and the highest contributing proportion of costs was from hospital admissions. A laparoscopic surgical approach was predictive of lower costs while age over 70 years and death at one year from diagnosis was predictive of higher costs. Conclusions: Regional variation exists in the treatment costs for patients with curative gastric cancer despite guidelines directing appropriate care and healthcare delivery in a universal healthcare system. Governmental intervention to ensure quality care delivery is necessary for improved and sustainable curative gastric cancer care across regions.

Preoperative Site Marking: Are We Adhering to Good Surgical Practice?

Wrong-site surgery is a never event and a serious, preventable patient safety incident. Within the United Kingdom, national guidance has been issued to minimize the risk of such events. The mandate includes preoperative marking of all surgical patients. This study aimed to quantify regional variation in practice within general surgery and opinions of the surgeons, to help guide the formulation and implementation of a regional general surgery preoperative marking protocol. A SurveyMonkey questionnaire was designed and distributed to 120 surgeons within the Mersey region, United Kingdom. This included all surgical trainees in Mersey (47 registrars, 56 core trainees), 15 consultants, and 2 surgical care practitioners. This sought to ascertain their routine practice and how they would choose to mark for 12 index procedures in general surgery, if mandated to do so. A total of 72 responses (60%) were obtained to the SurveyMonkey questionnaire. Only 26 (36.1%) said that they routinely marked all of their patients preoperatively. The operating surgeon marked the patient in 69% of responses, with the remainder delegating this task. Markings were visible after draping in only 55.6% of marked cases. Based on our findings, surgeons may not be adhering to "Good Surgical Practice"; practice is widely variable and surgeons are largely opposed and resistant to marking patients unless laterality is involved. We suggest that all surgeons need to be actively engaged in the design of local marking protocols to gain support, change practice, and reduce errors.