Tackling unwarranted variation, harm and waste is another theme revisited in the 2018 report. Unwarranted variation is variation that cannot be explained by need, or by patient or population preferences and can identify over-treatment, under-treatment, and over use of interventions that may result in harm. A Value Based Healthcare Work Programme was introduced with the appointment of Realistic Medicine Leads who undertook Value Improvement and Atlas of Variation training. [The Scottish Government. Practising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2016-17. Published 2018. https://www.gov.scot/publications/practising-realistic-medicine/]
The Scottish Atlas of Variation has now been published as part of the Tackling Unwarranted Variation, with new maps being introduced on a regular basis. [https://www.isdscotland.org/Products-and-Services/Scottish-Atlas-of-Variation/] “The Atlas highlights geographical variation in the provision of health and care services and associated health outcomes across Scotland.” It is not intended to explain the variation, be a measure of performance, or reflect the quality of care, but rather used as a tool for clinicians to identify, investigate, discuss variations and ultimately promote quality improvement. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]
Below is a selection of journal articles and reports which are about unwarranted variation in healthcare. If you are looking to answer a specific question please submit a literature search request at the link above. If you would like to be alerted when new content is available here then please sign in and select Follow. You are welcome to leave comments and suggestions below in the comments section.
ABEL, G. and ELLIOTT, M.N., 2019. Identifying and quantifying variation between healthcare organisations and geographical regions: using mixed-effects models. BMJ Quality & Safety,
When quantifying the degree of variation between healthcare organisations or geographical regions, the role of chance if often unaccounted for, which can lead to an overestimation of the true variation. The role of chance can be accounted for using mixed-effects models to estimate the true/underlying variation between organisations or regions. In this paper, a random intercept model is applied to rate or proportion indicators and how to interpret the estimated variance parameter is explored.
Alvarez-Galvez, J. Jaime-Castillo, AM., 2018. The impact of social expenditure on health inequalities in Europe. Social Science & Medicine 200:9-18.
Welfare states are assumed to play a fundamental role in the protection and promotion of the health and socioeconomic well-being of citizens. However, empirical evidence on the effect of the welfare state is still contradictory. The inconsistency of the results has led researchers to a lack of consensus in defining the mechanisms that might explain the relationship betweent he welfare state and health. To shed some light on the current debate, we relyon individual and country data from the Europeean Social Survey (ESS) and Eurostat to explore the direct and indirect effects of the welfare state on health inequalities in a sample of European countries. We use multilevel models to test the hypothesized impact of social expenditure on reducing health inequalities. Firstly, results show that health inequalities are lower in countries where social expenditure is higher. Secondly, the relationship between socioeconomic status (ESES) and health is moderated by social expenditure. The positive effect of SES on health decreqases in countries where social expenditure is higher,w hile this effect is higher in countries with lower social expenditure. The positive effect of SES on health decreases in countries where social expenditure is higher, while this effect is higher in countries with lower social expenditure. Our findings suggest that social spending has a positive impact on equalizing health conditions in Europe.
Appleby, J., Raleigh, V., Frosini, F., et al. (2011) Variations in health care: the good, the bad and the inexplicable. The King’s Fund. (accessed 01/09/2015)
Recommendations (page vii-viii)
- Systematic and routine collation and publication of data on ... variations
- a programme of work not only to identify causes of variation at specific local level, but also to prioritise those variations and causes
- local health organisations ... to be required to publicly justify and explain in a consistent way their relative position on key aspects of health care variation.
- explore the development of harder-edged, locally focused incentives to encourage action to deal with unwarranted variation
- encouragement of shared decision making to establish the right level of variation based on patients’ own assessments of needs and risk aversion
“If all variation were bad, solutions would be easy. The difficulty is in reducing the bad variation, which reflects the limits of professional knowledge and failures in its application, while preserving the good variation that makes care patient centred. When we fail, we provide services to patients who don’t need or wouldn’t choose them while we withhold the same services from people who do or would, generally making far more costly errors of overuse than of underuse.” (Mulley 2010) (page vii)
“But the now formidable literature on clinical practice variation shows that this is not necessarily so. Studies have suggested that the principal driver of variation in per capita spending in the US is not from variations in costs per admission but in rates of admission (Gottlieb et al 2010) and that there was scope by tackling admission rate variations to reduce spend on Medicare (for the elderly) by nearly 30 per cent ($40 billion) (Wennberg et al 2002). Indeed, there is scope to make efficiency
savings by reducing discretionary admissions that can harm patients.” (page 5)
GUTACKER, N., et al, 2018. Should interventions to reduce variation in care quality target doctors or hospitals? Health Policy. 122(6): 660-666.
Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably. These issues are explored in the context of the English NHS by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute MI, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010-February 2013. Performance indicators defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations. Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.
Harrison, R., Manias, E., Heslop, D., Hinchcliff, R., Hay, L. (2019) Addressing unwarranted clinical variation: A rapid review of current evidence. Journal of Evaluation in Clinical Practice, 15 May.
Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness.
Hart, R., Burns, G., Smith, S. (2018) Applying realistic medicine to intrathecal opioid utilisation in Scotland: do we have a standardised approach. British Journal of Pain 12(1):5-9.
Intrathecal opioids (ITOs) are commonly administered as part of a multimodal anaesthetic strategy for a variety of surgical procedures. The evolution of laparoscopic surgical techniques has seen the popularity of ITOs increase as they are effective, well tolerated and lack the cardiovascular side effects associated with epidural infusions. The risk of delayed respiratory depression remains a concern; therefore, high-quality post-operative monitoring is vital. The evidence regarding the practicalities of ITO administration such as opioid dose, type, side effect prevalence and ideal post-operative care arrangements are sparse. As such, a variety of clinical opinion has been generated. In order to quantify this variation within Scotland, we devised a short telephone questionnaire regarding ITO utilisation. We contacted 16 acute surgical sites. Of these, 14 confirmed regular utilisation of ITOs. Our survey demonstrated significant variability in practice. Both diamorphine and morphine are utilised, but no centre could provide a reason to justify the choice of one over the other. The commonly administered dose range for both agents ranged between 100 and 1100micro g. Most centres employed post-operative monitoring geared towards the detection of delayed respiratory depression but this was not unanimous. Each centre had a variation on what observations nursing staff were expected to complete in the post-operative period. Itch and nausea were not encountered frequently. Two centres experienced at least one episode of delayed respiratory depression which was detected and treated with no patient harm. In the report to the Scottish Government, 'Realistic Medicine', by the Chief Medical Officer, the need to reduce unnecessary variation in practice and outcomes is highlighted. We believe that a national sprint audit would gather sufficient prospective data to further determine whether a correlation exists between side effect profile and ITO utilisation practice. We hope this would help form a consensus and guide a standardised approach.
NHS Institute for Innovation and Improvement. Variation: an overview. 2008.
Click here (last accessed 11/09/2015)
Includes tools to measure variation - see under Step 3: Is the source of the variation mainly artificial? & Step 4 : Do you understand the real cause of variation?
Skinner, J. Causes and consequences of regional variations in health care. Handbook of Health Economics, Volume 2. 2012. ISSN 1574-0064.
https://www.dartmouth.edu/~jskinner/documents/Skinner_CausesandConsequences.pdf (last accessed 11/09/2015)
“… consider regional health care differences in the context of a simple demand and supply model, and then focus on the empirical evidence documenting causes of variations. While demand factors are important … there remains strong evidence for supply-driven differences in utilization. I then consider evidence on the causal impact of spending on outcomes, and conclude that it is less important how much money is spent, and far more important how the money is spent” (page 45)
“The regional variations literature reviewed typically appears in the health services research literature and is not always visible to the practicing health economist.” (page 85)
“existing regional variations in health care utilization are symptomatic of an enormous lack of knowledge about what works and what does not in health care.” (page 86)
TIMMINS, N., 2017. Tackling variations in clinical care: assessing the Getting It Right First Time (GIRFT) programme. London: King's Fund.
The Getting It Right First Time (GIRFT) programme aims to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices.
It uses national data to identify the variations and outcomes, shares that data with all those concerned with a service – not only clinicians, but also clinical and medical directors, managers and chief executives – and monitors the changes that are implemented.
The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the English NHS. Through an informal assessment of the programme, this paper sets out what the programme is, why it is needed, what is different about it, what it has achieved, what challenges it faces and what potential it has. It also contains vignettes illustrating hospitals’ experiences of the programme.
SUTHERLAND, K. and LEVESQUE, J., 2019. Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework. Journal of evaluation in clinical practice,
“This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.”