Let’s get it together!Exploring variation in clinical practice        Kishore Visvanathan, MD FRCSC  Clinical Professor, U...
Variation = Loss of confidence
Get your act together! Office manager Nurses Cancer clinic pharmacist
Variation = Confusion
Average patient recall rate (%) May - August 200830.0025.0020.0015.0010.00 5.00 0.00        C    D        I       F       ...
Variation = Waste
Dartmouth Atlas - Variation in Care Delivery
TURP for enlarged prostate 9.5 per 1,000 males   Idaho Falls, Idaho 1.7 per 1,000 Medicare beneficiaries   Terre Haute...
Surgery for prostate cancer 3.8 per 1,000 men over 65   San Luis Obispo, California 0.3 per 1,000 men over 65   Albany...
Prostate cancer   treatment           2X           Surgery vs.           Radiation
Tu, J. et al, CMAJ Feb 7, 2012
Variation = Inappropriate care (?)
Reduce Variation      ^ Un wan ted
Sources of variationSystemProviderDisease processPatient preference
Average patient recall rate (%) May - August 200830.0025.0020.0015.0010.00 5.00 0.00        C    D        I       F       ...
Sooner, Safer, Smarter
Prostate cancer surgery                 2X
Variation is a symptom,          not the disease
…Variation is a thief. It robs from processes, productsand services the qualities they are                 intended to have.
Unintended variation is stealing        healthcare blind today.  …recover a bounty in wasted resources that would dwarf th...
Controlling Variation in            Health Care   Donald M. Berwick        Medical CareDecember 1991, 29(12)          pp 1...
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
K. Visvanathan - Exploring Variation in Clinical Practice
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K. Visvanathan - Exploring Variation in Clinical Practice

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  • Shows the graphic product of the Dartmouth project
  • OK, one more prostate example: surgery for prostate cancer. That’s not a minor procedure. Men must be paying attention to the decision to have surgery. Especially when it carries the risk of incontinence and impotence. Response: Yes, this appears to be a very significant difference. And the likely explanation is practice patterns in the USA. There may not be enough urologists in Georgia and the population is underserviced. I will also admit that this operation pays the surgeon very well in a private practice setting. That may be a factor in the US. I can assure you that you wouldn’t see such a variation in Canada… (wait for it!)
  • Variation in rates of PCI:CABG in selected Ontario hospitals
  • K. Visvanathan - Exploring Variation in Clinical Practice

    1. 1. Let’s get it together!Exploring variation in clinical practice Kishore Visvanathan, MD FRCSC Clinical Professor, University of Saskatchewan Division Head, Urology, Saskatoon Health Region
    2. 2. Variation = Loss of confidence
    3. 3. Get your act together! Office manager Nurses Cancer clinic pharmacist
    4. 4. Variation = Confusion
    5. 5. Average patient recall rate (%) May - August 200830.0025.0020.0015.0010.00 5.00 0.00 C D I F E B G A H Doctor
    6. 6. Variation = Waste
    7. 7. Dartmouth Atlas - Variation in Care Delivery
    8. 8. TURP for enlarged prostate 9.5 per 1,000 males  Idaho Falls, Idaho 1.7 per 1,000 Medicare beneficiaries  Terre Haute, Indiana
    9. 9. Surgery for prostate cancer 3.8 per 1,000 men over 65  San Luis Obispo, California 0.3 per 1,000 men over 65  Albany, Georgia More than 12X different!
    10. 10. Prostate cancer treatment 2X Surgery vs. Radiation
    11. 11. Tu, J. et al, CMAJ Feb 7, 2012
    12. 12. Variation = Inappropriate care (?)
    13. 13. Reduce Variation ^ Un wan ted
    14. 14. Sources of variationSystemProviderDisease processPatient preference
    15. 15. Average patient recall rate (%) May - August 200830.0025.0020.0015.0010.00 5.00 0.00 C D I F E B G A H Doctor
    16. 16. Sooner, Safer, Smarter
    17. 17. Prostate cancer surgery 2X
    18. 18. Variation is a symptom, not the disease
    19. 19. …Variation is a thief. It robs from processes, productsand services the qualities they are intended to have.
    20. 20. Unintended variation is stealing healthcare blind today. …recover a bounty in wasted resources that would dwarf the puny rewards of cost- containment to date. Berwick, 1991
    21. 21. Controlling Variation in Health Care Donald M. Berwick Medical CareDecember 1991, 29(12) pp 1212-25

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