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Introduction: Clinical guidelines and quality improvement initiatives have identified reducing the use of end‐of‐life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life. Methods: Using Surveillance, Epidemiology, and End Results–Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation. Results: Patients' median age at the time of death was 74 years (interquartile range, 69–79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end‐of‐life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end‐of‐life cancer therapy (OR, 4.42; 95% CI, 4.00–4.89). Conclusions: Oncologists show substantial variation in end‐of‐life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision‐making can reduce overuse of end‐of‐life cancer therapies. We examined the extent to which oncologists differed in prescribing systemic therapies to their patients in the last 30 days of life. Results showed substantial variation in end‐of‐life prescribing behavior, with oncologists in the 95th percentile exhibiting a 45% adjusted rate of treatment, compared to just 17% among oncologists in the 5th percentile. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to evaluate the clinical relevance, diagnostic procedures and treatment strategies for metabolic bone disease in preterm infants across Europe. Methods: An e‐survey was distributed by email to 545 neonatal units in 38 European countries between July and October 2021. The protocol was based on the Checklist for Reporting Results of Internet E‐Surveys. Results: In total, 76 neonatal units (14%) from 22 European countries (58%) completed the e‐survey. In the 12 months prior to the survey, 29% of 76 units reported at least one symptomatic case of fracture associated with metabolic bone disease of prematurity, and 18% of 76 units reported at least one case of craniofacial deformity. Most centres followed local guidelines for diagnosis (77% of 73 units) and treatment (63% of 72 units). Alkaline phosphatase was the blood marker most used for treatment indication (81% of 72 units), and phosphate supplementation was the treatment most used (82% of 71 units). Conclusion: Metabolic bone disease of prematurity remains clinically relevant. Wide variations in diagnostic procedures and management strategies were observed in European neonatal units. Evidence‐based consensus guidelines appear urgently needed to reduce the number of symptomatic cases. [ABSTRACT FROM AUTHOR]

Introduction: A successful living donor liver transplant (LDLT) is the culmination of a multifaceted process coordinated among key stakeholders. Methods: We conducted an electronic survey of US liver transplant (LT) centers (August 26, 2021–October 10, 2021) regarding attitudes, barriers, and facilitators of LDLT to learn how to expand LDLT safely and effectively in preparation for the American Society of Transplantation Living Donor Liver Transplant Consensus Conference. Results: Responses were received from staff at 58 programs (40.1% of US LT centers). There is interest in broadening LDLT (100% of LDLT centers, 66.7% of non‐LDLT centers) with high level of agreement that LDLT mitigates donor shortage (93.3% of respondents) and that it should be offered to all suitable candidates (87.5% of respondents), though LDLT was less often endorsed as the best first option (29.5% of respondents). Key barriers at non‐LDLT centers were institutional factors and surgical expertise, whereas those at LDLT centers focused on waitlist candidate and donor factors. Heterogeneity in candidate selection for LDLT, candidate reluctance to pursue LDLT, high donor exclusion rate, and disparities in access were important barriers. Conclusion: Findings from this study may help guide current and future expansion of LDLT more efficiently in the US. These efforts require clear and cohesive messaging regarding LDLT benefits, engagement of the public community, and dedicated resources to equitably increase LDLT access. [ABSTRACT FROM AUTHOR]

In the United States, living donor liver transplantation (LDLT) is limited to transplant centers with specific experience. However, the impact of recipient characteristics on procedure selection (LDLT vs. deceased donor liver transplant [DDLT]) within these centers has not been described. Transplant registry data for centers that performed ≥1 LDLT in 2002–2019 were analyzed using hierarchal regression modeling to quantify the impact of patient and center factors on the adjusted odds ratio (aOR) of LDLT (vs DDLT). Among 73,681 adult recipients, only 4% underwent LDLT, varying from <1% to >60% of total liver transplants. After risk adjustment, the likelihood of receiving an LDLT rose by 73% in recent years (aOR 1.73 for 2014‐2019 vs. 2002‐2007) but remained lower for older adults, men, racial and ethnic minorities, and obese patients. LDLT was less commonly used in patients with hepatocellular carcinoma or alcoholic cirrhosis, and more frequently in those with hepatitis C and with lower severity of illness (Model for End‐Stage Liver Disease (MELD) score < 15). Patients with public insurance, lower educational achievement, and residence in the Northwest and Southeast had decreased access. While some differences in access to LDLT reflect clinical factors, further exploration into disparities in LDLT utilization based on center practice and socioeconomic determinants of health is needed. [ABSTRACT FROM AUTHOR]

Aim: Worldwide, long‐term care tends to shift from institutional care towards home care. In order to deliver high‐quality and adequate care, the type, amount and cost of care is determined by a patient needs assessment. However, there are indications that this patient needs assessment varies between comparable patients. In the Netherlands, some home care organizations aim to improve patient needs assessments by implementing improvement measures to reduce this practice variation. The goal of this study was to explore the type and perceived impact of those implemented improvement measures. Design: A cross‐sectional explorative survey study was conducted among Dutch home care organizations between January and April 2021. Methods: An online questionnaire with 26 items was developed by the research team, which was distributed through Dutch nationwide home care sector organizations, the Dutch nurses' association (V&VN) and the Dutch society for home care nursing (NWG). Results: The survey was completed by 184 respondents, including home care nurses, managers and staff who are responsible for training, policy and quality of care. Intervision and peer review for home care nurses were the most common reported improvement measures that were implemented in home care organizations. The experiences of those improvement measures have been perceived as creating greater uniformity in the patient needs assessment, making home care nurses feel more supported and secure performing their patient needs assessment and that the provided care is more in line with patients' demand. Our findings give insights into type and perceived impact of improvement measures that Dutch home care organizations implemented. Further research is needed to find out whether improvement measures actually improve patient needs assessments and reduce practice variation. [ABSTRACT FROM AUTHOR]

Wounds continue to be of a global concern. Therefore, a more focussed, evidence‐based approach to wound assessment and management is required. The WOUND COMPASS™ Clinical Support App (CSA) is designed to support the health care professional with wound assessment and management at the point of care. This real‐world pilot study aimed to determine the utility of the CSA during routine wound management, in multiple care settings. A non‐interventional, real‐world pilot programme of the CSA was conducted at four sites. Patients received routine wound management. The CSA was programmed to replicate the site's formulary for evidence‐based wound management. Anonymised pre‐ and post‐pilot clinician opinion surveys on useability and impact of the CSA were collected and reported. Wound Specialists (n = 7 [100%]) and Non‐Wound Specialists (NWS) (n = 58 [82%]) indicated that competence and confidence in wound assessment were enhanced with use of the CSA (100%; 82%). Furthermore, practice variation was reduced because of a greater compliance to their local formulary (n = 7 [100%]; 79% [54%]). This real‐world pilot shows the positive impact of the CSA, and the improvements that can be potentially realised via reduction in practice variation, improvement in NWSs confidence when managing wounds and increased formulary compliance. [ABSTRACT FROM AUTHOR]

Background: Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically., Methods and Results: From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization., Conclusions: Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

It is well recognized in the literature that practice variation is an integral part of diffusion processes. What remains less explored is the emergence of distinct forms of a novel practice and the interdependencies in their diffusion. In this study, we make a distinction between the pure version of a practice and ensuing hybrid variants and investigate how diffusion processes unfold for these alternative practice forms. Our empirical investigation in the Turkish higher education field demonstrates that hybrid practice forms became viable alternatives to the pure version of instruction in English and diffused in an interdependent manner. Further, diffusion of pure and hybrid forms was uneven across private and public universities. Our study contributes to the diffusion and practice variety literature as we establish that multiple versions of a practice that diffuse concurrently in a field may be building on or hampering each other, and they may diffuse in fragmented ways across different sub‐populations. [ABSTRACT FROM AUTHOR]

Background: The pediatric Appropriate Use Criteria (AUC) for outpatient transthoracic echocardiography (TTE) aim to reduce practice variation. Little is known on variation in TTE use between physicians. Understanding this variation will help identify areas for improvement in standardization of TTE use. Methods and Results: This is a retrospective review of initial outpatient visits at 6 pediatric cardiology centers in the United States prior to AUC release. Variation in TTE use was examined using multilevel generalized mixed effects models. Forward selection identified combinations of variables that explained the most variance in TTE use between physicians. Due to collinearity, physician compensation model and center were analyzed separately. Of 2883 encounters, the most common indication was murmur (36%), followed by chest pain (15.2%). Overall TTE use was 41.9%, and varied widely between centers (22.9%‐52.6%), and between physicians within centers. Center alone explained 29% of this physician variance. Adding physician characteristics increased the variance explained to 57%, which only minimally improved by adding patient characteristics. The variance explained was driven by subspecialty. The center‐based multivariable model explained more variance over compensation model. Conclusions: Center was the single largest determinant of physician variance in TTE use, followed by physician subspecialty. Efforts to reduce practice variation, such as the AUC, should be employed across centers and all pediatric cardiac providers. Center appears to have a stronger impact on variance than compensation model, though in this dataset the effect of center and compensation are hard to separate from each other and deserve further evaluation. [ABSTRACT FROM AUTHOR]

Background: Prostate cancer is the most common male cancer, with a wide range of treatment options. Payment reform to reduce unnecessary spending variation is an important strategy for reducing waste, but its magnitude and drivers within prostate cancer are unknown.Methods: In total, 38,971 men aged ≥66 years with localized prostate cancer who were enrolled in Medicare fee-for-service and were included in the Surveillance, Epidemiology, and End Results-Medicare database from 2009 to 2014 were included. Multilevel linear regression with physician and facility random effects was used to examine the contributions of urologists, radiation oncologists, and their affiliated facilities to variation in total patient spending in the year after diagnosis within geographic region. The authors assessed whether spending variation was driven by patient characteristics, disease risk, or treatments. Physicians and facilities were sorted into quintiles of adjusted patient-level spending, and differences between those that were high-spending and low-spending were examined.Results: Substantial variation in spending was driven by physician and facility factors. Differences in cancer treatment modalities drove more variation across physicians than differences in patient and disease characteristics (72% vs 2% for urologists, 20% vs 18% for radiation oncologists). The highest spending physicians spent 46% more than the lowest and had more imaging tests, inpatient care, and radiotherapy spending. There were no differences across spending quintiles in the use of robotic surgery by urologists or the use of brachytherapy by radiation oncologists.Conclusions: Significant differences were observed for patients with similar demographics and disease characteristics. This variation across both physicians and facilities suggests that efforts to reduce unnecessary spending must address decision making at both levels. [ABSTRACT FROM AUTHOR]

Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER-TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed-effects multinomial regression to quantify the effects on pre-hospital or in-hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre-hospital and 483 (13%) in-hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre-hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1-4.3) for pre-hospital intubation, and 2.7 (95%CI 1.9-3.5) for in-hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre-hospital intubation (OR 2.9, 95%CI 1.3-6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3-0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between-centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation. [ABSTRACT FROM AUTHOR]

It has long been recognized that there is significant variation in the way that centers approach clinical management and problems within pediatric transplantation. This has recently been highlighted in two publications by the PHTS showing practice variation in both surveillance for cardiac allograft vasculopathy and diagnosis of acute rejection. These differences in practice are important to recognize and serve as the foundation for collaborative learning, developing research questions, and implementing quality improvement initiatives. To further understand the practice variation within the society, and to begin the process of learning from each other, the society has developed a Clinical Approach Working Group, whose task is to tackle issues seen in transplant and integrate current literature with clinical protocols and experience from the individual sites. The early work of this group has results in the series of Clinical approach articles presented in this issue of Pediatric Transplantation. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, Aims, and Objectives: The physician is often implicated as an important cause of observed variations in health care service use. However, it is not clear if physician‐related variation is problematic for patient care. This paper illustrates that observed physician‐related variation is not necessarily unwarranted. Methods: This is a narrative review. Results: Many studies have attributed observed variations to the physician, but little attention is given towards discriminating between those variations that exist for good reasons and those that are unwarranted. Two arguments can be made for why physician‐related variation is unwarranted. The first posits that physician‐related factors should not play a role in management of care decisions because such decisions should be driven by science (which is imagined to be definitive). The second considers the possibility of supplier‐induced demand as a factor driving observed variations. We show that neither argument is sufficient to rule out that physician‐related variations may be warranted. Furthermore, the claim that such variations are necessarily problematic for patients has yet to be substantiated empirically. Conclusions: It is not enough to simply show that physician‐related variation can exist—one must also show where it is unwarranted and what is the magnitude of unwarranted variations. Failure to show this can have significant implications on how we interpret and respond to observed variations. Improved measurement of the sources of variation, especially with respect to patient preferences and context, may help us start to disentangle physician‐related variation that is desirable from that which is unwarranted. [ABSTRACT FROM AUTHOR]

Universal access and generous coverage are important goals of the Dutch long-term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010-December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long-term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long-term IC. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation. Methods We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups. Results Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance. Conclusion Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation. [ABSTRACT FROM AUTHOR]

Purpose Antibiotic prophylaxis is critical to ophthalmology and other surgical specialties. We performed natural language processing (NLP) of 743 838 operative notes recorded for 315 246 surgeries to ascertain two variables needed to study the comparative effectiveness of antibiotic prophylaxis in cataract surgery. The first key variable was an exposure variable, intracameral antibiotic injection. The second was an intraoperative complication, posterior capsular rupture (PCR), which functioned as a potential confounder. To help other researchers use NLP in their settings, we describe our NLP protocol and lessons learned. Methods For each of the two variables, we used SAS Text Miner and other SAS text-processing modules with a training set of 10 000 (1.3%) operative notes to develop a lexicon. The lexica identified misspellings, abbreviations, and negations, and linked words into concepts (e.g. 'antibiotic' linked with 'injection'). We confirmed the NLP tools by iteratively obtaining random samples of 2000 (0.3%) notes, with replacement. Results The NLP tools identified approximately 60 000 intracameral antibiotic injections and 3500 cases of PCR. The positive and negative predictive values for intracameral antibiotic injection exceeded 99%. For the intraoperative complication, they exceeded 94%. Conclusion NLP was a valid and feasible method for obtaining critical variables needed for a research study of surgical safety. These NLP tools were intended for use in the study sample. Use with external datasets or future datasets in our own setting would require further testing. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Aim: To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs).Methods: A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice.Results: In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes.Conclusion: There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies. [ABSTRACT FROM AUTHOR]

Introduction: Large practice variation exists in mode of delivery after cesarean section, suggesting variation in implementation of contemporary guidelines. We aim to evaluate this practice variation and to what extent this can be explained by risk factors at patient level.Material and Methods: This retrospective cohort study was performed among 17 Dutch hospitals in 2010. Women with one prior cesarean section without a contraindication for a trial of labor were included. We used multivariate logistic regression analysis to develop models for risk factor adjustments. One model was derived to adjust the elective repeat cesarean section rates; a second model to adjust vaginal birth after cesarean rates. Standardized rates of elective repeat cesarean section and vaginal birth after cesarean per hospital were compared. Pseudo-R2 measures were calculated to estimate the percentage of practice variation explained by the models. Secondary outcomes were differences in practice variation between hospital types and the correlation between standardized elective repeat cesarean section and vaginal birth after cesarean rates.Results: In all, 1068 women had a history of cesarean section, of whom 71% were eligible for inclusion. A total of 515 women (67%) had a trial of labor, of whom 72% delivered vaginally. The elective repeat cesarean section rate at hospital level ranged from 6 to 54% (mean 29.8, standard deviation 11.8%). Vaginal birth after cesarean rates ranged from 50 to 90% (mean 71.8%, standard deviation 11.1%). More than 85% of this practice variation could not be explained by risk factors at patient level.Conclusion: A large practice variation exists in elective repeat cesarean section and vaginal birth after cesarean rates that can only partially be explained by risk factors at patient level. [ABSTRACT FROM AUTHOR]

Background: Rural communities have disproportionately faced primary care shortages for decades in spite of policy efforts to prepare and attract primary care health professionals to practice in rural locales. Insight into how primary care physicians’ service patterns in rural areas differ from those in less rural places is important to better inform recruitment strategies that target primary care providers and rural communities. Objectives: The purpose of this research is to describe how primary care physician service patterns vary by rural‐urban location for a large, privately insured population. We discuss implications of service pattern variation on policy efforts to attract primary care providers to underserved rural areas. Methods: Claims data from fully insured commercial health insurance beneficiaries were used to develop service pattern profiles for primary care providers located in 1 of 4 types of rural‐urban areas in Iowa in 2009. The 4 area types are metropolitan, micropolitan, noncore area adjacent to a metro area, and noncore/nonadjacent rural area. Results: There were differences in primary care physicians’ service patterns by rural‐urban area type. Physicians in nonmetropolitan areas provided relatively more care on a per physician basis than those in the metropolitan area type, as well as more surgery, maternity, emergency, and nursing facility services than metropolitan physicians. Conclusion: Primary care physicians who value practicing a relatively diverse range of services may find locating in rural areas an appealing choice. Health systems and policy makers seeking to attract primary care physicians to rural areas can incorporate this reality into a recruitment strategy. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Surgical research struggles to describe the relationship between procedural variations in daily practice and traditional conceptualizations of evidence. The problem has resisted simple solutions, in part, because we lack a solid understanding of how surgeons conceptualize and interact around variation, adaptation, innovation, and evidence in daily practice. This grounded theory study aims to describe the social processes that influence how procedural variation is conceptualized in the surgical workplace. Method Using the constructivist grounded theory methodology, semi-structured interviews with surgeons ( n = 19) from four North American academic centres were collected and analysed. Purposive sampling targeted surgeons with experiential knowledge of the role of variations in the workplace. Theoretical sampling was conducted until a theoretical framework representing key processes was conceptually saturated. Results Surgical procedural variation was influenced by three key processes. Seeking improvement was shaped by having unsolved procedural problems, adapting in the moment, and pursuing personal opportunities. Orienting self and others to variations consisted of sharing stories of variations with others, taking stock of how a variation promoted personal interests, and placing trust in peers. Acting under cultural and material conditions was characterized by being wary, positioning personal image, showing the logic of a variation, and making use of academic resources to do so. Our findings include social processes that influence how adaptations are incubated in surgical practice and mature into innovations. Conclusions This study offers a language for conceptualizing the sociocultural influences on procedural variations in surgery. Interventions to change how surgeons interact with variations on a day-to-day basis should consider these social processes in their design. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The objective of this study was to examine the rates and geographic variation of endoscopic sinus surgery (ESS) in a representative sample of the US working population. Study Design Observational cohort study using the MarketScan Commercial Claim and Encounters database. Methods All patients who received ESS between 2009 and 2013 were included. The annual adjusted rates of ESS per 1,000 people were calculated for each US state. Geographic variations were evaluated using the extremal quotient (EQ), weighted coefficient of variation (CV), systematic component of variance (SCV), and empirical Bayes statistic. The χ2 statistic tests was used to quantify variation of the adjusted ESS rates across states within the US. Results The annual adjusted rate of ESS was 0.94 per 1,000 people in the US. South Dakota and Alabama were observed to have the highest rates of ESS, 1.80 and 1.69, respectively. Vermont and Arkansas were observed to have the lowest rates of ESS, 0.51 and 0.57, respectively. The mean EQ was 4.54, indicating a four- to fivefold difference between the highest (South Dakota) and lowest (Vermont) states. The mean CV was 31.4 and mean SCV was 10.1, which demonstrates very high variation. Conclusions This study observed very high geographic variation in the rates of ESS across the United States. Given that practice variation indicates the presence of potentially harmful and inefficient unwarranted care, outcomes from this study indicate a need to further evaluate the delivery of ESS to improve overall health system performance. Level of Evidence 2b. Laryngoscope, 125:1772-1778, 2015 [ABSTRACT FROM AUTHOR]

Background The threshold model represents an important advance in the field of medical decision-making. It is a linchpin between evidence (which exists on the continuum of credibility) and decision-making (which is a categorical exercise - we decide to act or not act). The threshold concept is closely related to the question of rational decision-making. When should the physician act, that is order a diagnostic test, or prescribe treatment? The threshold model embodies the decision theoretic rationality that says the most rational decision is to prescribe treatment when the expected treatment benefit outweighs its expected harms. However, the well-documented large variation in the way physicians order diagnostic tests or decide to administer treatments is consistent with a notion that physicians' individual action thresholds vary. Methods We present a narrative review summarizing the existing literature on physicians' use of a threshold strategy for decision-making. Results We found that the observed variation in decision action thresholds is partially due to the way people integrate benefits and harms. That is, explanation of variation in clinical practice can be reduced to a consideration of thresholds. Limited evidence suggests that non-expected utility threshold (non- EUT) models, such as regret-based and dual-processing models, may explain current medical practice better. However, inclusion of costs and recognition of risk attitudes towards uncertain treatment effects and comorbidities may improve the explanatory and predictive value of the EUT-based threshold models. Conclusions The decision when to act is closely related to the question of rational choice. We conclude that the medical community has not yet fully defined criteria for rational clinical decision-making. The traditional notion of rationality rooted in EUT may need to be supplemented by reflective rationality, which strives to integrate all aspects of medical practice - medical, humanistic and socio-economic - within a coherent reasoning system. [ABSTRACT FROM AUTHOR]

Background Diagnosis of pulmonary hypertension (PH) is often delayed or missed, leading to disease progression and missed treatment opportunities. In this study, we measured variation in care provided by board-certified cardiologists and pulmonologists in simulated patients with potentially undiagnosed PH. Methods and Results In a cross-sectional study (https://www.clinicaltrials.gov, NCT04693793), 219 US practicing cardiologists and pulmonologists cared for simulated patients presenting with symptoms of chronic dyspnea and associated signs of potential PH. We scored the clinical quality-of-care decisions made in a clinical encounter against predetermined evidence-based criteria. Overall, quality-of-care scores ranged from 18% to 74%, averaging 43.2%±11.5%. PH, when present, was correctly suspected 49.1% of the time. Conversely, physicians incorrectly identified PH in 53.7% of non-PH cases. Physicians ordered 2-dimensional echocardiography in just 64.3% of cases overall. Physicians who ordered 2-dimensional echocardiography in the PH cases were significantly more likely to get the presumptive diagnosis (61.9% versus 30.7%; P <0.001). Ordering other diagnostic work-up items showed similar results for ventilation/perfusion scan (81.5% versus 51.4%; P =0.005) and high-resolution computed tomography (60.4% versus 43.2%; P =0.001). Physicians who correctly identified PH were significantly more likely to order confirmatory right heart catheterization or refer to PH center (67.3% versus 15.8%; P <0.001). Conclusions A wide range of care in the clinical practice among simulated patients presenting with possible PH was found, specifically in the evaluation and plan for definitive diagnosis of patients with PH. The delay or misdiagnosis of PH is likely attributed to a low clinical suspicion, nonspecific symptoms, and underuse of key diagnostic tests. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04693793.

Objectives Little is known about the contribution of telephone-based prescribing on overall antibiotic utilization. The objective of this study was to determine the extent and characteristics of telephone-based antibiotic prescribing in teaching and non-teaching primary care practices. Methods This retrospective cohort study included all patients ( n = 114 610) cared for by teaching and non-teaching internal medicine, pediatrics, family practice, and obstetrics/gynecology practices ( n = 19) affiliated with a large US healthcare system during 2006-2010 and using a common electronic medical record. Rates and types of antibiotics prescribed by teaching and non-teaching practices via telephone contact and office visit were compared among the overall cohort. All telephone-related prescriptions during 2008 underwent chart review to determine indications for antibiotic prescribing. Results Overall, 28.9 antibiotic prescriptions were issued per 100 patient-years, with 63 418 total antibiotic prescriptions and 7876 (12.4%) generated after telephone contact. Telephone-based prescribing increased steadily from 2.2 to 4.2 per 100 patient-years during the study period. Both telephone-based and office-based antibiotic prescribing were higher in non-teaching practices. Of 1790 antibiotics prescribed by telephone during 2008, the majority were for urinary tract infection (28.3%), sinusitis (20.1%), and unspecified upper respiratory infection (URI, 15.0%). Conclusions Overall, one in every eight antibiotics was prescribed via telephone encounter. These data highlight the need to include the impact of this practice in analysis of outcomes associated with outpatient antibiotic prescribing and to incorporate telephonic prescribing into guidelines facilitating appropriate antibiotic use. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

While magnetic resonance imaging ( MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results ( SEER)-Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient- and physician-level predictors of preoperative MRI utilization. Of 56,743 women with early-stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% ( n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient-level factors and physicians' volumes. Accounting for clustering of patients within individual physicians ( n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early-stage breast cancer improves clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals. Study Design Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database. Methods There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions. Results Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA. Conclusions Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night. Level of Evidence 4. Laryngoscope, 123:2561-2567, 2013 [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis The purpose of this study was to examine factors associated with prophylactic placement of feeding tubes in head and neck cancer patients receiving radiation therapy as a part of treatment using multilevel models that account for patient-, physician-, and institution-level sources of variation. Study Design A retrospective analysis using binary logistic regression and hierarchical linear models was run to evaluate independent predictors of prophylactic feeding tube placement. Methods Surveillance, Epidemiology, and End Results-Medicare data were used. Head and neck cancer patients diagnosed with locoregionally advanced stage disease from 2000 to 2005 were included in this study (N = 8,306). Results Across all models, prophylactic gastrostomy tube placement was found to be more likely in patients who had cancer of the larynx or oropharynx compared with those with cancer of the nasopharynx or oral cavity; who had regional instead of local cancer; who did not receive surgery as a part of treatment, but did receive chemotherapy; and who were divorced, separated, or widowed. Additionally, although practice variation was observed to occur, its overall contribution in predicting prophylactic gastrostomy tube placement was minimal. Conclusions As health care enters an era of patient-centered care, further investigation of the potential role of social support (or lack of social support) in influencing treatment decisions of head and neck cancer patients and providers is warranted. Level of Evidence 2b Laryngoscope, 123:1918-1925, 2013 [ABSTRACT FROM AUTHOR]

Objectives To simulate physician-driven dynamics of delivery mode decisions (scheduled cesarean delivery [ CD] vs. vaginal delivery [ VD] vs. unplanned CD after labor), and to evaluate a behavioral theory of how experiential learning leads to emerging bias toward more CD and practice variation across obstetricians. Data Sources/Study Setting Hospital discharge data on deliveries performed by 300 randomly selected obstetricians in Florida who finished obstetrics residency and started practice after 1991. Study Design We develop a system dynamics simulation model of obstetricians' delivery mode decision based on the literature of experiential learning. We calibrate the model and investigate the extent to which the model replicates the data. Principal Findings Our learning-based simulation model replicates the empirical data, showing that physicians are more likely to schedule CD as they practice longer. Variation in CD rates is related to the way that physicians learn from outcomes of past decisions and accumulate experience. Conclusions The repetitive nature of medical decision making, learning from past practice, and accumulating experience can account for increases in CD decisions and practice variation across physicians. Policies aimed at improving medical decision making should account for providers' feedback-based learning mechanisms. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the return to work and health outcomes of a physiotherapy network provider programme. Method A prospective case-control study was conducted with 21 clients of network occupational physiotherapy (OP) providers and 21 matched clients of non-network providers. Outcome measures Health outcomes and return to work were recorded 3 and 6 months following the commencement of physiotherapy. Health outcomes included the Short Form (SF)-12, return to usual activities and the global perceived effect of treatment. Within-group changes and between-group differences were analysed. Results Within-group changes showed the OP group improved significantly in physical functioning ( p = 0.006), and the control group deteriorated in mental health status ( p = 0.016) as measured by the SF-12. Mean change over time between groups from the 3-month to 6-month follow-ups showed a significant difference favouring the OP group for return to usual activities ( p = 0.027) and the physical component of the SF-12 ( p = 0.009). All job-attached participants returned to work following their accident, so there was no difference between the groups. Conclusion The OP clients demonstrated a greater change in physical functioning health outcomes over time. This study provides preliminary support for the implementation of the OP scheme. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyse the inter-hospital variation in the appropriateness of cataract phacoemulsification in Spain. This observational, multicentre, prospective study involved patients aged 18-90 years. Each phacoemulsification intervention was classified as 'necessary', 'appropriate', 'uncertain' or 'inappropriate' according to explicit appropriateness criteria previously established using the RAND/UCLA methodology. A descriptive statistical analysis was performed, followed by univariate and multivariate logistic regression analysis, in order to examine the differences between hospitals. In total, 5063 patients from 15 hospitals were enrolled. The percentage of patients in each hospital who inappropriately underwent phacoemulsification varied from 1.2% to 24.0% ( P < 0.0001). The most common inappropriate scenario was that of patients with a simple, unilateral cataract with no limitation of their visual function, with a pre-surgery visual acuity of ≥0.5 in both eyes, and for whom surgical correction would involve low technical complexity. The variation in appropriateness of phacoemulsification cannot be attributed solely to the clinical differences between the hospitals' patients. There is room for improvement in the appropriate indication of phacoemulsification. Measures based on the dissemination of appropriateness criteria might improve quality of care. [ABSTRACT FROM AUTHOR]

Background: Treatment completion rates for hepatitis C virus (HCV) infection in clinical practice settings are unknown. Methods: We assembled a national cohort of HCV-infected veterans-in-care from 1998 to 2003, using the VA National Patient Care Database for demographical/clinical information, Pharmacy Benefits Management database for pharmacy records and the Decision Support Systems database for laboratory data. We used logistic regression to determine the factors predicting treatment non-completion for HCV. Results: We identified 134 934 HCV-infected veterans of whom 16 043 [11.9%; 95% confidence interval (CI) 11.7–12.1] were prescribed treatment for HCV. Among the 10 641 veterans with >1 year of follow-up, 2396 (22.5%; 95% CI 21.7–23.3) completed a 48-week course. Non-completers were more likely to have pre-treatment anaemia, coronary artery disease, depression, substance abuse, used standard interferon, higher comorbidity count, and been treated at a low-volume treatment site (defined as sites initiating HCV treatment for <200 individuals). In multivariable analyses, treatment completion was positively associated with pegylated interferon use [odds ratio (OR) 1.59, 95% CI 1.40–1.80] and site treatment volume (OR 1.87, 95% CI 1.56–2.24 for sites initiating treatment for >200 individuals) and negatively associated with pre-treatment anaemia (OR 0.68, 95% CI 0.58–0.80 for haemoglobin 10–14 g/dl) and depression (OR 0.78, 95% CI 0.69–0.89). Human immunodeficiency virus coinfection and minority race were not associated with failing to complete treatment. Conclusions: Among veterans-in-care with known HCV, 11.9% initiate therapy of whom 22.5% (one in 56 with known HCV infection) complete a 48-week course of treatment. Higher completion rates among higher volume treatment sites suggest that some factors associated with non-completion (pre-treatment depression and anaemia), may be modifiable with experience. [ABSTRACT FROM AUTHOR]

Objectives. To examine the extent of variation in public health agency spending levels across communities and over time, and to identify institutional and community correlates of this variation. Data Sources and Setting. Three cross-sectional surveys of the nation's 2,900 local public health agencies conducted by the National Association of County and City Health Officials in 1993, 1997, and 2005, linked with contemporaneous information on population demographics, socioeconomic characteristics, and health resources. Study Design. A longitudinal cohort design was used to analyze community-level variation and change in per-capita public health agency spending between 1993 and 2005. Multivariate regression models for panel data were used to estimate associations between spending, institutional characteristics, health resources, and population characteristics. Principal Findings. The top 20 percent of communities had public health agency spending levels >13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health agency spending was inversely associated with local-area medical spending. Conclusions. The mechanisms that determine funding flows to local agencies may place some communities at a disadvantage in securing resources for public health activities. [ABSTRACT FROM AUTHOR]

Objectives The surgical management and outcome of outpatient care for patients with simple lacerations were compared across three institutions. We examined the variations in wound infection rate, total charge and medical resource use in terms of prophylactic antibiotic prescription, frequency of outpatient visits and required days for stitch removal. Design Retrospective and consecutive chart review. Study participants Patients receiving treatment for simple lacerations in the outpatient departments of three institutions in Japan between June 2000 and August 2001. Outcome measures and method The basic patient characteristics, treatment method for the laceration and incidence of wound infection were collected. Variations in the wound infection rate were examined across the institutions. We then examined the variations in the medical resource use and total charge for patients without wound infection among the institutions by multiple linear regression model. Results A total of 479 patients were reviewed. The proportion of patients with blunt injury, patients with simple lacerations to the head or face, and those with underlying medical disease were significantly different among the three institutions. The wound infection rate did not significantly differ (1.9% in Institution A, 1.3% in B, 3.0% in C, P = 0.555). The medical resource use for patients without wound infection was significantly different and small in Institution A. Conclusion We identified variations in the resource use for completing wound care among three institutions, whereas the wound infection rate revealed no significant difference among the institutions. There existed some room for improvement in the productive efficiency of simple laceration treatment. [ABSTRACT FROM AUTHOR]

Purpose To determine nurse practitioners' (NPs') knowledge and reported practices regarding breast cancer screening in a climate of conflicting guidelines. Data Source A descriptive, cross-sectional survey design was used to examine approaches to cancer screening among NPs in western New York. Conclusions Among the 175 NP respondents, agreement with the accepted answer for the individual breast cancer-screening items ranged from 51% to 80%; responses did not vary by age group or gender. Overall, 54% demonstrated agreement with three or more of four breast cancer-screening items. Implications for Practice These findings suggest the need to implement educational interventions as one means of decreasing variation in breast cancer screening among NPs. Also, the development and endorsement of a single set of evidence-based breast cancer-screening guidelines would promote adoption of a single screening recommendation. [ABSTRACT FROM AUTHOR]

There is considerable variability in donor acceptance practices among adult heart transplant providers; however, pediatric data are lacking. The aim of this study was to assess donor acceptance practices among pediatric heart transplant professionals. The authors generated a survey to investigate clinicians' donor acceptance practices. This survey was distributed to all members of the ISHLT Pediatric Council in April 2018. A total of 130 providers responded from 17 different countries. There was a wide range of acceptable criteria for potential donors. These included optimal donor‐to‐recipient weight ratio (lower limit: 50%‐150%, upper limit: 120%‐350%), maximum donor age (25‐75 years), and minimum acceptable left ventricular EF (30%‐60%). Non‐US centers demonstrated less restrictive donor selection criteria and were willing to accept older donors (50 vs 35 years, P < 0.001), greater size discrepancy (upper limit weight ratio 250% vs 200%, P = 0.009), and donors with a lower EF (45% vs 50%, P < 0.001). Recipient factors were most influential in the decision to accept marginal donors including recipients requiring ECMO support, ventilator support, and highly sensitized patients with a negative XM. However, programmatic factors impacted the decision to decline marginal donors including recent programmatic mortalities and concerns for programmatic restrictions from regulatory bodies. There is significant variation in donor acceptance practices among pediatric heart transplant professionals. Standardization of donor acceptance practices through the development of a consensus statement may help to improve donor utilization and reduce waitlist mortality. [ABSTRACT FROM AUTHOR]

Background Direct acting oral anticoagulants (DOACs) theoretically could contribute to addressing underuse of anticoagulation in non-valvular atrial fibrillation (NVAF). Few studies have examined this prospect, however. The potential of DOACs to address underuse of anticoagulation in NVAF could be magnified within a healthcare system that sharply limits patients' exposure to out-of-pocket copayments, such as the Veterans Health Administration (VA). Methods and Results We used a clinical data set of all patients with NVAF treated within VA from 2007 to 2016 (n=987 373). We examined how the proportion of patients receiving any anticoagulation, and which agent was prescribed, changed over time. When first approved for VA use in 2011, DOACs constituted a tiny proportion of all prescriptions for anticoagulants (2%); by 2016, this proportion had increased to 45% of all prescriptions and 67% of new prescriptions. Patient characteristics associated with receiving a DOAC, rather than warfarin, included white race, better kidney function, fewer comorbid conditions overall, and no history of stroke or bleeding. In 2007, before the introduction of DOACs, 56% of VA patients with NVAF were receiving anticoagulation; this dipped to 44% in 2012 just after the introduction of DOACs and had risen back to 51% by 2016. Conclusions These results do not suggest that the availability of DOACs has led to an increased proportion of patients with NVAF receiving anticoagulation, even in the context of a healthcare system that sharply limits patients' exposure to out-of-pocket copayments.