Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association

Screening for important unwarranted variation in clinical practice: a triple-test of processes of care, costs and patient outcomes

Andrew Partington A , Derek P. Chew B , David Ben-Tovim B , Matthew Horsfall C , Paul Hakendorf B and Jonathan Karnon A D

A School of Public Health, University of Adelaide, Level 7, 178 North Terrace, Adelaide, SA 5044, Australia. Email:

B School of Medicine, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia. Email:;;

C South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia. Email:

D Corresponding author. Email:

Australian Health Review 41(1) 104-110
Submitted: 2 June 2015  Accepted: 1 February 2016   Published: 3 March 2016


Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice.

Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators.

Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients’ presenting characteristics and time of presentation.

Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives.

What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality.

What does this paper add? This paper proposes the comparative analysis of processes of care, costs and outcomes for patients with similar diagnoses presenting at alternative hospitals, using linked, routinely collected data. This triple test of performance indicators extracts maximum value from routine data to identify priority areas for quality improvement to reduce important and unwarranted variations in clinical practice.

What are the implications for practitioners? The proposed analyses need to be applied to other clinical areas to demonstrate the general application of the methods. The outputs can then be validated through the application of quality improvement initiatives in clinical areas with identified important and unwarranted variation. Validated frameworks for the comparative analysis of clinical practice provide an efficient approach to valuing and prioritising actions to improve health service quality.


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