Variation In Utilization Rates Research Articles

Managing unwarranted variation in hospital care – findings from a regional audit in Norway

Background/AimThere has been increasing focus and research over the past decades on defining, identifying, visualizing and reducing unwarranted clinical variation in clinical practice. Both clinician-driven initiatives such as the US based “Choosing Wisely” campaign and the top-down driven “Evidence-based intervention programme (EBI)” launched by NHS UK to improve quality of care by reducing unnecessary interventions have shown marginal results. We present the findings from a mixed-methods audit performed to evaluate the compliance by senior hospital leaders of a new regional strategy to reduce unwarranted variation in outcomes and utilization rates.MethodsSeventy-five mid- to senior-division and department leaders from eight hospital trusts in South-Eastern Norway Regional Trust (HSO) were invited to participate in evaluating the response and compliance of the regional leadership strategy for reducing unwarranted variation in patient outcomes and service utilization rates.ResultsThe audit revealed that the aim of reducing unwanted variation was not clearly communicated by senior HSO management. There was varying use of data from the national quality registers and health atlases for quality improvement. One third of the clinical leaders reported a lack of scrutiny of their work and were insufficiently aware of the HSO’s top-management and the hospital’s Boards strategic expectations about the importance of reducing unwarranted variation in their hospital utilization.ConclusionsWe found that the strategic aim of reducing unwanted clinical variation was not clearly communicated by senior HSO management to hospital boards and senior management.The hospitals could benefit from a better understanding of causes of variation by strengthening their efforts to reduce unwarranted variation in utilization rates as a key element in improving health care quality and patient safety. The findings of the audit are relevant for other healthcare organizations trying to improve their quality and reduce unnecessary variation.

Variability in Resource Utilization in the Evaluation and Management of Simple Febrile Seizures Inpatients in US Children's Hospitals.

To characterize resource utilization in the evaluation and treatment of hospitalized simple febrile seizure (SFS) patients in US tertiary pediatric hospitals. This is a retrospective cohort study using the Pediatric Health Information System from 2010 to 2015. Children 6 months to 5 years of age who were inpatients with a diagnosis of SFS. Children who had brain magnetic resonance imaging (MRI), electroencephalography (EEG), or received anticonvulsants were compared with those who did not have testing or anticonvulsant treatment. Hospital-level variation in the utilization rates of MRI, EEG, or treatment with anticonvulsants was also evaluated. In Pediatric Health Information System-participating institutions, 8.4% (n=3640) of children presenting to the emergency department with SFS were hospitalized. Among these SFS inpatients, 57.8% (n= 2104) did not receive further evaluation with MRI/EEG or treatment with anticonvulsants. There was evidence of wide inter-hospital variation in resource utilization rates. The median (interquartile range) utilization rate was 6.2% (3.0 to 11.0%) for MRI, 28.5% (16.0 to 46.3%) for EEG and 17.1% (10.9 to 22.3%) for treatment with anticonvulsants. No specific hospital-level factors were identified that contributed to the variation in resource utilization in the evaluation and management of hospitalized SFS patients.

Population-wide contribution of medically assisted reproductive technologies to overall births in Australia: temporal trends and parental characteristics.

Population-wide contribution of medically assisted reproductive technologies to overall births in Australia: temporal trends and parental characteristics.

Variations in use and access of mental health services in Europe

Abstract Background Mental illnesses comprise a wide range of mental health (MH) conditions -prevalence 3,90%- among European (EU) countries with significant effects on quality of life, life expectancy and disability. They are also related to substantial direct and indirect costs, consequences of inpatient care - not always beneficial for those patients. The main goals of our study are: to report on geographic variations in utilization rates and quality of care for adults MH diseases among 30 EU countries and regions; to explain the determinants of such variations. Methods Different data from EUROSTAT regarding healthcare resources, activities and self-perceived health and wellbeing for the years 2013-2015 are combined in a unique database at level of EU countries and NUTS 2 regions to allow for comparisons in utilization rates, perceived conditions and service local supply for MH diseases in Europe. Results Preliminary findings show a decline in the global trend of hospitalization rates for mental diseases; however, significant variations were observed among and within countries (High-Low ratio=25 in 2015, at country level). Males were more hospitalized than females (p = 0.40). Women were more likely than men to report depressive symptoms and to access to MH consultations (p < 0.001). Significant and positive correlations were found between resources (hospital beds and psychiatrists per capita) and adjusted hospitalization rates for MH disorders and between self-reported MH consultations and psychiatrists per capita (p < 0.001). Conclusions Preliminary findings confirm the presence of wide variations in the care of mental diseases across and within EU countries. Significant correlations between utilization rates and local supply of resources might indicate that part of the variation might be explained by differences in the local organization and availability of resources rather than patients' needs. Key messages There is a wide variation in the care of mental diseases across and within EU countries which might be explained by differences in the local organization and resources instead patients’ needs. These results can help policy makers and professionals to identify unwarranted variations that need to be removed and to shift to value-based healthcare.

Cross-national comparison of levothyroxine utilization in four developed countries

Context: While hypothyroidism is prevalent globally, there may be considerable variation in the use of therapies to treat this condition. Aims: The aim was to examine temporal trends of levothyroxine utilization in Canada, Greece, Ireland and the United States. Settings and Design: A cross-sectional, population-based time series study was conducted to assess monthly utilization rates from January 1, 2005 to September 20, 2011, in Canada, Greece, Ireland and the United States. The primary outcome measure was the monthly rate of levothyroxine utilization for each country analyzed. Materials and Methods: Levothyroxine utilization data were obtained from IMS Health Inc., and temporal trends in monthly units dispensed per 1,000 population were examined. Statistical Analysis Used: Time series analysis was used to examine temporal trends in levothyroxine utilization. Results: While levothyroxine utilization rates increased over time in all regions, considerable differences were noted between regions - 80% relative difference in average monthly utilization between the highest (Greece - 1,664 units/1,000 population) and lowest (Ireland - 925 units/1,000 population) utilization countries was observed. We observed a nearly 3.5-fold difference in utilization of moderate-to-high strength doses (100 μg+) of levothyroxine between the countries examined. Conclusions: We noted considerable regional variation in the use of levothyroxine. Further research is needed to understand the drivers of these variations in utilization rates.

Variability of Preoperative Breast MRI Utilization among Older Women with Newly Diagnosed Early-stage Breast Cancer

While magnetic resonance imaging (MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results (SEER)-Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient- and physician-level predictors of preoperative MRI utilization. Of 56,743 women with early-stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% (n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient-level factors and physicians' volumes. Accounting for clustering of patients within individual physicians (n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early-stage breast cancer improves clinical outcomes.

Improving Value in Healthcare

Improving Value in Healthcare

Is there much variation in variation? Revisiting statistics of small area variation in health services research

BackgroundThe importance of Small Area Variation Analysis for policy-making contrasts with the scarcity of work on the validity of the statistics used in these studies. Our study aims at 1) determining whether variation in utilization rates between health areas is higher than would be expected by chance, 2) estimating the statistical power of the variation statistics; and 3) evaluating the ability of different statistics to compare the variability among different procedures regardless of their rates.MethodsParametric bootstrap techniques were used to derive the empirical distribution for each statistic under the hypothesis of homogeneity across areas. Non-parametric procedures were used to analyze the empirical distribution for the observed statistics and compare the results in six situations (low/medium/high utilization rates and low/high variability). A small scale simulation study was conducted to assess the capacity of each statistic to discriminate between different scenarios with different degrees of variation.ResultsBootstrap techniques proved to be good at quantifying the difference between the null hypothesis and the variation observed in each situation, and to construct reliable tests and confidence intervals for each of the variation statistics analyzed. Although the good performance of Systematic Component of Variation (SCV), Empirical Bayes (EB) statistic shows better behaviour under the null hypothesis, it is able to detect variability if present, it is not influenced by the procedure rate and it is best able to discriminate between different degrees of heterogeneity.ConclusionThe EB statistics seems to be a good alternative to more conventional statistics used in small-area variation analysis in health service research because of its robustness.

Issues on the measurement of the Solow residual and the testing of its exogeneity: Evidence for Canada

This paper examines the impact of adjusting the Solow residual for variable capacity utilization on the empirical assessment of market structure and exogeneity of productivity shocks. Making use of an innovative measure of capacity utilization available in Canada reveals that its aggregate market structure is well described by constant returns to scale and perfect competition in contrast to most studies which do not make this adjustment. Furthermore, when the capital stock is adjusted for variations in utilization rates, Canadian productivity shocks are exogenous to real and monetary variables.

Risk stratification for cesarean delivery using a regional database

Objective: To distinguish between patients at high and low risk for undergoing cesarean delivery using a regional database.Methods: As part of a large metropolitan regional evaluation of variation and quality of care regarding childbirth, we developed a risk stratification tool using ICD-9-CM codes accounting for the likelihood of undergoing cesarean delivery from 26,358 consecutive deliveries between July 1997 and June 1998 in 22 hospitals. A previous cesarean delivery was intentionally not classified as high risk.Results: There were 5,017 cesarean deliveries (19%) performed. Ten of 24 studied conditions placed a patient at high risk for cesarean delivery: malposition (breech [87%], face/brow [84%], high head at term [88%], transverse or oblique presentation [77%], and unspecified malposition [81%]), obstruction from malpositioned fetus at labor onset (95%), placenta previa (59%), severe preeclampsia (51%), premature separation of placenta (50%), and prolapsed cord (67%).Conclusion: Our approach differs from alternative methods of assessing maternal risk because it does not define a high-risk pregnancy, but rather identifies patients at high risk for cesarean delivery. This approach has merit when attempting to determine variation in rates of utilization for cesarean delivery across patients, physicians, hospitals, and regions of the country.

Geographic variations in utilization rates in Veterans Affairs hospitals and clinics.

In the United States, geographic variation in hospital use is common. It is uncertain whether there are similar geographic variations in the health care system of the Department of Veterans Affairs (VA), which differs from the private sector because it predominantly serves men with annual incomes below $20,000, has a central system of administration, and uses salaried physicians. Thus, it might be less likely to have geographic variations. We used VA data bases to obtain information on patients treated for eight diseases (chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, and major depression). We analyzed their use of hospital and outpatient services by assessing the risk-adjusted numbers of hospital days (the average number of days a patient spent in the hospital per 12 months of follow-up, regardless of the number of hospital stays), hospital-discharge rates, and clinic-visit rates from 1991 through 1995 for the entire system and within the 22 geographically based health care networks. We found substantial geographic variation in hospital use for all eight cohorts of patients and all the years studied. Variations in the numbers of hospital days per person-year among the networks were greatest among patients with chronic obstructive pulmonary disease (ranging from a factor of 2.7 to a factor of 3.1) during a given year and smallest among patients with angina (ranging from a factor of 1.5 to a factor of 2.1). Levels of hospital use were highest in the Northeast and lowest in the West. The variation in the rates of clinic visits for principal medical care among the networks ranged from a factor of approximately 1.6 to a factor of 4.0; variations in the rates were greatest among patients with chronic renal failure and smallest among patients with chronic obstructive pulmonary disease. There was no clear geographic pattern in the rates of outpatient-clinic use. There are significant geographic variations in the use of hospital and outpatient services in the VA health care system. Because VA physicians are unable to increase their income by changing their patterns of practice, our findings suggest that their practice styles are similar to those of other physicians in their geographic regions.

Report on Variation in Rates of Utilization of Surgical Services in the Commonwealth of Massachusetts

This article presents an analysis of over 140,000 selected surgical procedures performed in Massachusetts in 1980, giving the per capita rates of 14 common procedures and of four less frequently performed procedures. The analysis defines 172 geographic areas for the commonly performed procedures and 45 for the less frequently performed procedures. Per capita surgical rates among the defined areas are significantly different from both a statistical and a clinical point of view. Twofold and threefold variations occur frequently across geographic areas. In certain areas, some surgical services appear to be provided at rates substantially different from the statewide rate. We discuss the importance of these data for physicians as well as the implications for the distribution and quality of clinical care and for containment of medical care costs.

Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts

Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts