Screening for important unwarranted variation in clinical practice: a triple-test of processes of care, costs and patient outcomesAndrew 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: email@example.com
C South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia. Email: Matthew.Horsfall@sa.gov.au
D Corresponding author. Email: firstname.lastname@example.org
Australian Health Review 41(1) 104-110 http://dx.doi.org/10.1071/AH15101
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.
References Australian Commission on Safety and Quality in HealthCare (ACSQHC). Medical practice variation: background paper. Sydney: ACSQHC; 2013
 Mulley AJ. Improving productivity in the NHS. BMJ 2010; 341 c3965
| Improving productivity in the NHS.CrossRef |
 Lilford R, Mohammed MA, Spiegelhalter D, Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet 2004; 363 1147–54.
| Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma.CrossRef | 15064036PubMed |
 Australian Commission on Safety and Quality in HealthCare (ACSQHC). FAQs clinical care standards. Sydney: ACSQHC; 2014.
 Pidun T, Felden C, Limitations of performance measurement systems based on key performance indicators. Proceedings of the Seventeenth Americas Conference on Information Systems, Detroit, Michigan August 4–7 2011. Paper 14. Available at: http://aisel.aisnet.org/cgi/viewcontent.cgi?article=1013&context=amcis2011_submissions [verified 12 February 2016].
 Australian Commission on Safety and Quality in HealthCare (ACSQHC). Using hospital mortality indicators to improve patient care: a guide for boards and chief executives. Sydney: ACSQHC; 2014.
 Lilford RJ, Brown CA, Nicholl J. Use of process measures to monitor the quality of clinical practice. BMJ 2007; 335 648–50.
| Use of process measures to monitor the quality of clinical practice.CrossRef | 17901516PubMed |
 Independent Hospital Pricing Authority (IHPA). Pricing framework for Australian public hospital services 2015–16. Sydney: Independent Hospital Pricing Authority; 2014.
 Duckett S, Coory M, Kamp M, Collins J, Skethcher-Baker K, Walker K. VLADs for dummies. Milton, Qld: Wiley Publishing Australia Pty Ltd; 2008.
 Glick HA, Doshi JA, Sonnad SS, Polsky D. Economic evaluation in clinical trials. Oxford: Oxford University Press; 2007.
 Nelson EC, Eftimovska E, Lind C, Hager C, Wasson JH, Lindblad S. Patient reported outcome measures in practice. BMJ 2015; 350 g7818
| Patient reported outcome measures in practice.CrossRef | 25670183PubMed |
 Scott IA, Brand CA, Phelps GE, Barker AL, Cameron PA. Using hospital standardised mortality ratios to assess quality of care: proceed with extreme caution. Med J Aust 2011; 194 645–8.
| 21692724PubMed |
 Mason J, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond M. When is it cost-effective to change the behaviour of health professionals? JAMA 2001; 286 2988–92.
| When is it cost-effective to change the behaviour of health professionals?CrossRef | 1:STN:280:DC%2BD38%2FivFWrsg%3D%3D&md5=9583767c603320bb07c896a590da867bCAS | 11743840PubMed |