Expanding precision medicine calls for reducing unwarranted variation. This has been on the radar of providers, payers, and policymakers for over 40 years. The Economist Intelligence Unit summarized recent literature to find out if identifying and implementing processes to reduce this variation leads to increased value of care.
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Introduction
Unwarranted variation in healthcare has been on the radar of providers, payers, and policymakers for over 40 years. The term refers to variation in medical practices that cannot be explained by illness, medical need, patient preferences, or the recommendations of evidence-based medicine. The Economist Intelligence Unit reviewed the recent evidence regarding the effectiveness of attempts to reduce unwarranted variation in healthcare settings, with a particular focus on interventions at the hospital level. They identified two high-quality reviews and 34 primary studies published since 2012.
Which approaches have been tried?
The review revealed a range of approaches used to try and reduce unwarranted variation. More than half of the included studies used a combination of approaches. Based on the main component, the interventions can be grouped into three broad categories: evidence-based approaches, medical technologies, and care-delivery system interventions. The goal of reducing variation requires both technical and non-technical approaches, because successful implementation requires behavior change in healthcare providers.
Which approaches have been successful?
Most of the studies focused on describing a particular approach in a specific setting, so it was difficult to extrapolate results to other settings. The most striking finding was that, even though these were studies of interventions designed to reduce variation in healthcare, none of the studies reported change in variation as a quantitative outcome.
The authors therefore used “health services utilization” (defined as an increase in the use of appropriate or decrease in the use of inappropriate services) as a surrogate outcome for reduction in variation, and found that 20 of the 34 studies reported a significant improvement. The following specific interventions were associated with an improvement in health services utilization:
- Evidence-based approaches: Appropriateness criteria; clinical practice guidelines; care pathways; care delivery protocols; standardized clinical assessment and management plans (SCAMPs); and stewardship programs
- Medical technologies: Diagnostic technologies; computerized order sets; decision support systems; and laboratory forced-function systems
- Care delivery system interventions: Caseload care model; National Awareness and Early Diagnosis Initiative; and regional trauma networks
Only nine of the 34 studies measured the impact of the interventions for reduction of variation on direct medical costs, and all of these reported savings. Studies that reported patient outcomes found that approaches which improved service utilization did not cause significant harms to patients.
Recommendations
When it comes to delivering value, healthcare providers, payers, and policymakers need to focus their efforts to reduce unwarranted variation in clinical practice. Furthermore, they should escalate their efforts to redesign health systems in alignment with the principles of value-based healthcare.
The authors list the following recommendations for provider organizations and other stakeholders:
- Move to bundled payments
- Introduce integrated care delivery systems with multidisciplinary teams
- Measure costs and outcomes for individual patients
- Use IT tools such as decision-making systems or learning systems
