Variations in health care: the good the bad and the inexplicable

Appleby, J., Raleigh, V., Frosini, F., et al. (2011) Variations in health care: the good, the bad and the inexplicable. The King’s Fund. Available at http://www.kingsfund.org.uk/publications/variations-health-care (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)