Reducing Clinical Variation in Health Care

| Posted On Aug 20, 2015 | By:

Health care spending in the United States is growing at an unsustainable rate, and policy makers are seeking ways to slow growth and reduce spending. A key target is removing waste, or spending that could be eliminated without reducing the quality of care. Waste includes spending on services that lack evidence of producing better health outcomes, inefficiencies in the provision of health care services, and the treatment of avoidable medical injuries, such as preventable infections in hospitals. According to some estimates, waste may constitute one-third to nearly one-half of all US health care spending.

One way to identify and reduce waste is by assessing variation in clinical practices. Clinical variation in health care is defined as patients with similar diagnoses, prognoses and demographic characteristics receiving different levels of care depending on when, where and by whom they are treated. Variation in healthcare spending across the US is well documented. The Congressional Budget Office shows total per capita healthcare spending ranging from $4,000 in Utah to $6,700 in Massachusetts. Similarly, researchers with the Dartmouth Atlas Project found that among 306 hospital referral regions, Medicare spending ranged from $6,900 to more than $13,000 per patient.

What leads to clinical variation?

In an article in the Journal of Managed Care Pharmacy, Dr. Brent James of Intermountain Health Care wrote about clinical variation. Below are two contributing factors he discussed:

  1. An increasingly complex healthcare environment. Over the last 50 years, there have been huge changes in the way care is delivered. In the 1950s, physicians had a small number of medications to choose from. Now, it is estimated that there are more than 10,000 prescription drugs and 300,000 over-the-counter products available in the U.S. Modern imaging techniques, sophisticated intensive care units, transplant services, and a number of other complicated options have added to the complexity of care.
  2. Increasing medical knowledge. There is simply more information to keep up with. A 1991 study published in the Journal of the American Medical Association estimated that to maintain current knowledge, a general internist would need to read 20 articles a day, 365 days a year.

Additional factors include the geographical availability of services, the impact of provider training, and provider habits.

Clinical variation at Atrius Health

Within Atrius Health, there is clinical variation among sites and providers on some of our quality metrics, like imaging for acute low back pain, ordering screening tests for patients with diabetes, and blood pressure control for patients with hypertension.

At a medical practice of our size with more than 750 physicians, some variation is to be expected, based on differences in geography and patient demographics like age and socioeconomic status. However, some variation requires further exploration to understand why it exists. Atrius Health implemented practice pattern variation analysis (PPVA), which is an approach that uses data to uncover differences in clinical practice patterns and support conversations with providers about their clinical decision-making. The goal is to define evidence-based practice standards which reduce variation, drive waste out of the system, improve quality, and decrease costs.

An example of PPVA project that has led to measureable change in clinical practice at Atrius Health is the screening lab initiative. When the Atrius Health Quality Department began to track this metric in 2011, providers were ordering complete blood counts (CBC) for healthy patients during their yearly physical exams just over 30 percent of the time. A review of the available research and guidelines found that while CBCs are indicated for some patients, like those who are pregnant, there is no evidence to support routine CBC screening of asymptomatic patients in the general population. After the completion of an Atrius clinical guideline and provider education efforts, Atrius has reduced the rate of CBC ordering to just over 10 percent in 2014. Fewer CBCs means less blood draws, less unnecessary extra clinical visits and extra work-up due to false positive results. The reduction of unnecessary CBCs and other screening labs has also led to an estimated cost savings of more than $1 million.

Not all clinical variation projects aim to reduce services. The Quality Department is also using practice pattern variation analyses to improve care for patients on chronic opioid therapy. It is recommended that patients on chronic opioids receive a treatment agreement, have a regular urine drug screen, and are seen regularly by a primary care provider or pain specialist. You can read more about this initiative in this previous blog post about Opioid Prescription Monitoring at Atrius Health. By establishing organizational standards of care, offering education, and providing practice and provider-level data, sites have been able to improve these metrics, leading to more comprehensive patient care.

Atrius Health will continue to track clinical variation in a number of quality improvement efforts such as reducing the number of prescriptions written for antibiotics for children with viral respiratory illness, share the data with providers, and use the information to reduce waste and improve the care of our patients.

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