Unwarranted Practice Research Articles

Practice variation in induction of labor: A critical document analysis on the contribution of regional protocols.

Despite national guidelines with recommendations on induction of labor (IOL), large variation in the use of this intervention exists between regions in the Netherlands. Guidelines are translated into protocols, which give a contextual description of medical practice provided in a given region. Possibly, protocols developed by regional multidisciplinary maternity care networks (MCNs) contribute to the regional variation in IOL. The aim of this study was to assess the variation between regional protocols and national guidelines regarding recommendations on IOL and the extent to which this contributes to practice variation. We performed a systematic document analysis using the Ready materials, Extract data, Analyze, Distil (READ) approach. National guidelines (n = 4) and regional protocols (n = 18) from six MCNs on topics linked to IOL were assessed between October 2021 and April 2022. An analytical framework was used to extract data for the comparison of regional protocols. Some MCNs followed all the recommendations of national guidelines in their regional protocols, others developed their own recommendations, and for some this varied per topic. When developing their own recommendations, MCNs with a high percentage of IOL added additional risk factors and stricter cut-off values. In contrast, MCNs with a low percentage of IOL added more care options for continuing midwife-led care. No clear relationship was observed between the Appraisal of Guidelines for Research & Evaluation (AGREE) scores of the national guidelines and the extent to which regional protocols complied with the recommendations. The translation of national guidelines to regional protocols seemed arbitrary and not very systematic. To reduce unwarranted practice variation in the use of IOL, guidance is needed to better align regional protocols with national guidelines, while including appropriate contextual factors and allowing women's preferences. Additionally, healthcare providers should be trained in practicing evidence-based medicine instead of using evidence.

Nurses' decision-making around gastric residual volume measurement in UK adult intensive care: A four-centre survey.

Despite increasing evidence of the potential inaccuracy and unwarranted practice of regular GRV measurement in critically in adults, this practice persists within the United Kingdom. To explore adult intensive care nurses' decision-making around the practice of GRV measurement to guide enteral feeding. A cross-sectional 16 item electronic survey in four adult intensive care units (ICUs) in England and Wales. Two hundred and seventy-three responses were obtained across four ICUs with acceptable response rates for most [Unit 1 74 /127 = 58.2%; Unit 2 87/129 = 67.4%; Unit 3 77/120 = 64.1%; Unit 4 35/168 = 20.8%]. Most (243/273 (89%) reported measuring GRV 4-6 hourly, with most (223/273 82%) reporting that the main reason was to assess feed tolerance or intolerance and 37/273 (13.5%) saying their unit protocol required it. In terms of factors affecting decision-making, volume obtained was the most important factor, followed by the condition of the patient, with aspirate colour and appearance less important. When asked how they would feel about not measuring GRV routinely, the majority (78.2%) of nurses felt worried (140/273 = 51.2%) or very worried (74/273 = 27%). Factors affecting the nurses' decision-making around GRV were based largely on fear of risk (around vomiting and pulmonary aspiration) and compliance with unit protocols. Despite increasing evidence suggesting it is unnecessary, nurses' beliefs around the value of this practice persist and it continues to be embedded into unit protocols around feeding.

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

Unwarranted clinical practice variation and resource overutilization in medical care: The example of transfusion practices in elderly hospital patients

The ANZ hernia repair practices study: low consensus on inguinal and small ventral hernia management and infrequent long-term follow-up.

The ANZ hernia repair practices study: low consensus on inguinal and small ventral hernia management and infrequent long-term follow-up.

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study.

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices. Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity. Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas. There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

Cascade of decisions meet personal preferences in sciatica treatment decisions

Study designAn in-depth interview study including patients, general practitioners, neurologists and neurosurgeons.ObjectiveTo gain insight in decision-making in sciatica care, by identifying patients’ and physicians’ preferences for treatment options, and the...

Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience

Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience. To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience. This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021. The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities. Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits. In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.

Temporal Trends and Variation in Bronchoscopy Use for Acute Respiratory Failure in the United States

National data on bronchoscopy for the evaluation of acute respiratory failure are lacking, and the limited available data suggest wide variation in use. How commonly is bronchoscopy performed among hospitalizations with acute respiratory failure? How has use changed over time and across hospitals? This was an observational cohort study of adult hospitalizations (2012-2018) treated with invasive mechanical ventilation (IMV) using the National Inpatient Sample, which represents 97%of all hospitalizations in the United States. We measured the proportion of hospitalizations treated with IMV who underwent bronchoscopy and assessed trends in bronchoscopy use over time. Multilevel linear regression models were used to quantify hospital-level variation, adjusting for differences in patient and hospital characteristics. We identified 6,101,070 IMV-treated hospitalizations (2012-2018), of whom 609,405 underwent bronchoscopy; among hospitalizations receiving bronchoscopy, mean age was 61 years, 41.8%were women, and in-hospital mortality was 30.8%. The percentage of IMV-treated hospitalizations receiving bronchoscopy increased from 9.5%(95%CI, 9.1%-9.9%) in 2012 to 10.8%(95%CI, 10.4%-11.2%) in 2018 (P< .001 for difference). In 2018, bronchoscopy use varied from 0%to 57.1%among 1,787 hospitals, and in multilevel models adjusted for patient and hospital characteristics, 16.0%of the variation was explained at the hospital level. The median OR was 2.13 (95%CI, 2.05-2.21), indicating 113%increased odds of receiving bronchoscopy if moving from a lower-use to a higher-use hospital. Bronchoscopy use among hospitalizations treated with IMV has increased over time. The large variation in use of bronchoscopy across hospitals suggests potentially unwarranted practice variation and need for further studies to clarify which patients benefit from bronchoscopy.

To what extent do home care nurses feel free to assess the care that is needed for their patients? A nationwide survey in the Netherlands.

Background and AimsPatients receiving nursing care at home require a needs assessment. There are indications that practice variation exists in needs assessments performed by Dutch home care nurses. One possible cause is that nurses are differentially influenced by others when performing needs assessments. Instruments recommending what is appropriate care have the potential to protect nurses against unwarranted influences. In the Netherlands, a framework exists including general norms about performing needs assessments. We aimed to achieve insight into whether nurses, who have heard of the framework, feel more free to assess the care that is needed for their patients, and whether other actors play a role in performing needs assessments.MethodsAn online questionnaire was sent to members of the Dutch Nursing Staff Panel (response 47%; n = 302) in November 2019. Only nurses who perform needs assessments were included in the analyses (n = 141). χ2‐tests were used to assess the relationships between the variables of having heard of the framework, feeling free to assess the care that is needed, and the influences of others.ResultsWe found no relationships between having heard of the framework and feeling free to assess the care that is needed for patients or reporting influence of others. However, home care nurses who state that they are not influenced by others, feel more free to assess the care that is needed for their patients. In contrast, those who state that they are influenced by informal caregivers, or health care insurers, feel less free to assess the care that is needed.ConclusionIt appears that the framework for performing needs assessments does not, in its current form, protect against influences of others. Further research is recommended to examine what kind of instruments nurses need to perform unambiguous and good needs assessments and, as such, reduce unwarranted practice variation.

Temporal Trends and Hospital Variation in Time-to-Antibiotics Among Veterans Hospitalized With Sepsis

It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Time from presentation to antibiotic administration. The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P < .001). In multilevel models adjusted for patient characteristics, median time-to-antibiotics declined by 9.0 (95% CI, 8.8-9.2) minutes per calendar year. Temporal trends in time-to-antibiotics were similar across patient subgroups, but hospitals with faster baseline time-to-antibiotics had less change over time, with hospitals in the slowest tertile decreasing time-to-antibiotics by 16.6 minutes (23.1%) per year, while hospitals in the fastest tertile decreased time-to-antibiotics by 7.2 minutes (13.1%) per year. In the most recent years (2017-2018), median time-to-antibiotics ranged from 3.1 to 6.7 hours across hospitals (after adjustment for patient characteristics), 6.8% of variation in time-to-antibiotics was explained at the hospital level, and odds of receiving antibiotics within 3 hours increased by 65% (95% CI, 56%-77%) for the median patient if moving to a hospital with faster time-to-antibiotics. This cohort study across nationwide VA hospitals found that time-to-antibiotics for sepsis has declined over time. However, there remains significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment. Efforts to further accelerate time-to-antibiotics must be weighed against risks of overtreatment.

Developing critical thinking skills for delivering optimal care

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development.

A Knowledge Translation Framework for Optimizing Physical Therapy in Patients With Heart Failure.

The American Physical Therapy Association has supported the development of clinical practice guidelines to promote and support evidence-based practice and reduce unwarranted practice variation. Essential to the success of this effort is the generation of knowledge translation, a concept that emphasizes the translation of global knowledge to an application that can be effectively integrated into clinical practice. The Physical Therapy Clinical Practice Guideline for the Management of Individuals with Heart Failure published in the Physical Therapy Journal in January 2020 provides a broad base of knowledge related to evidence-based treatment interventions for patients with heart failure. However, the application and integration of this knowledge in clinical practice need further elucidation. Therefore, this perspective paper aims to serve as a complementary knowledge translation resource to the recently published practice guideline to maximize the utilization of contemporary evidence in clinical practice. This resource provides the physical therapist with practical guidance in the management of patients with heart failure by placing research findings in the context of other knowledge and practice norms that can be applied at the point of care and across the continuum of care. We propose a novel ABCDE (assessment, behavior modification, cardiorespiratory fitness, dosage, and education) practical framework. This clinical paradigm is grounded in ongoing physical therapist assessment throughout the episode of care, along with behavior modification, assessment of cardiorespiratory fitness, appropriate selection and dosing of interventions, and patient education. Examples highlighting the use of this model in patients with heart failure across the continuum of care are provided for application in clinical care.

Optimizing practice guidelines through incorporating patient and family values and preferences

Neonatal care largely follows clinical practice guidelines and position statements developed locally by respective institutions as well as by national and international organizations. One might expect that adoption of clinical guidelines based on best available research evidence would make neonatal care practices mostly uniform. However, wide variation in clinical practice is still noted in neonatal care. Neonatal clinical guidelines are developed almost exclusively by healthcare professionals, with little or no input from families of the infants being cared for. Therefore, such variation in practice may stem not only from how the evidence is interpreted but also how caregivers and families value different outcomes that are affected by particular interventions. Acknowledging and incorporating the variability in patient and family values and preferences in clinical guidelines is an important step towards allowing shared decision making while reducing unwarranted practice variation, and thereby helping clinicians practice family-centered evidence-based medicine.

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

BackgroundMedical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback.MethodsWe searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics).ResultsA total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%.ConclusionsStudy designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

National registries: Lessons learnt from quality improvement initiatives in intensive care.

National clinical quality registries (CQRs) are effective tools for improving the outcomes of patients admitted to the intensive care unit (ICU), and are increasingly important as healthcare needs evolve. A high-quality ICU CQR is built from a foundation of common requirements and challenges. First, performance indicators of the structure, process, or outcomes of patient care should measure what is important. Second, high data quality is essential and can be collected and curated through standardized processes. Third, standardized mortality ratio (SMR) is a cornerstone for benchmarking ICU performance, but application requires a comprehensive understanding of its context and potential pitfalls. Fourth, data collection alone is insufficient. Quality improvement comes from closing the feedback loop by identifying and managing unwarranted practice variation. Fifth, the process of improving healthcare is fundamentally a human enterprise, subject to behavioural change, including those that modify performance. Sixth, ICU CQRs must be dynamic to meet the needs of an evolving healthcare system and stakeholders. Finally, these lessons are far from comprehensive. Sharing perspectives on the development of ICU CQRs can help maximise their value as a powerful platform for informing policy development and improving the outcomes of patients admitted to the ICU.

Understanding practice variation with a clinical pathways system: Differences by physician and practice factors, and changes in practice over time.

2079 Background: Clinical oncology pathways aim to support clinical decision-making and reduce unwarranted practice variation across an enterprise. The Dana-Farber Cancer Institute (DFCI) implemented web-based oncology pathways with DFCI-customized content in each disease center and at each of its satellites. Our pre-specified aim was an on-pathway rate of 70-85%. Methods: Treatment decisions were electronically captured as on- or off- pathway. Monthly metrics about usage and on-pathway rate were shared with users on a monthly basis. Physicians were categorized into quintiles based on the calculated on-pathway performance during the first 90 days of each individual’s use of the platform. On-pathway rates were then calculated for days 91-360 to study changes in behavior over time. Physician and practice factors were examined to determine any differences by initial on-pathway quintile classification. Results: 122 physicians were eligible for inclusion in this analysis (minimum 5 navigations in each study period). On-pathway rates showed significant variability in the initial 90-day period: quintile 1 median 100%, quintiles 2-4 80.2%, and quintile 5 50% (Table). In the follow-up period, median on-pathway rates shifted into the pre-specified goal range for all groups. Physicians in quintiles 1 or 5 of initial on-pathway rate were more likely to have fewer total navigations than were physicians in quintiles 2-4 (p=0.003). While no other physician or practice characteristic differed significantly by on-pathway rate group, physicians in the first or last quintile were more likely to be in an academic setting, have a PhD, or navigate fewer pathways. Conclusions: Over time, the deployment of a web-based clinical pathways program resulted in greater uniformity in physician practice, based on on-pathway rate. Familiarity with the pathways platform and its navigation, monthly feedback about usage, and evolution of content over time are some factors that might have played a role. [Table: see text]

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

BackgroundHigh-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.MethodsSub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.ResultsAfter excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P < 0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P < 0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].ConclusionsFacility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Maximizing quality of life remains an ultimate goal in the era of precision medicine: exemplified by lung cancer.

An ultimate goal of precision medicine in lung cancer treatment is to restore patient health with maximized quality of life (QOL). Results from Mayo Clinic studies show that a significant improvement in fatigue, dyspnea, and pain scales could lead to better overall QOL. Although treatments and guidelines for clinical implementation to alleviate these key symptoms are available, few cancer patients receive adequate therapy, mostly because of limitations in current care delivery systems and unclear clinicians’ roles. For optimal care of lung cancer survivors in different subpopulations, three barriers must be overcome: physicians’ lack of knowledge, unwarranted practice variation, and uncertainty regarding care provider roles. Appropriate culturally adapted, tested and validated tools for QOL measures must be developed, rather than directly translating existing tools between different languages and across cultures or diverse subpopulations. Finally, lack of sensitive, adequate, and relevant tools in measuring health-related QOL (HRQOL) has long been an issue for effective data collection, demanding a global consensus on a set of core components that reflect the needs of all critical parties for the best cure and care, supporting patients to achieve optimal HRQOL.

Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study.

The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.

A Patient Decision Aid for Men With Localized Prostate Cancer: A Comparative Case Study of Natural Implementation Approaches.

There are multiple options for men diagnosed with localized prostate cancer. Patient decision aids (PtDAs) help empower individuals and reduce unwarranted practice variation, but few are used in clinical practice. We compared 2 programs implementing PtDAs for men with localized prostate cancer. This was a comparative case study. Case 1 was a hospital prostate pathway and case 2 was a provincial prostate pathway with 2 locations (2a, 2b). Nurses provided the men with PtDAs and answered questions. Data sources were as follows: (a) 2 years administrative data for men with localized prostate cancer, (b) clinicians survey and interviews, and (c) patients/spouses interviews. Analysis was within and across cases. The PtDA was used with 23% of men in case 1 (95% confidence interval, 19.8%-26.1%) and 98% of men in case 2a (95% confidence interval, 96.5%-99.8%). The pathway was not implemented in case 2b. Men given the PtDA had positive experiences. Many clinicians supported the use of PtDAs, some adapted their discussions with patients, and others did not support the use of PtDAs. To increase use in case 1, participants identified needing a Canadian PtDA available electronically and endorsed by all clinicians. In case 2b, the provincial prostate pathway needed to be implemented. There was variable uptake of the PtDAs between the cases. Men who received the PtDA had positive outcomes. Several strategies were identified to increase or sustain PtDA use. Nurses have a key role in supporting men making decisions about prostate cancer treatment by providing PtDAs, answering questions, and advocating for men's preferences.