Variation

Variation
Siân Williams, IPCRG Executive Officer
IPCRG Biennial Conference May 2008

© IPCRG 2007

The 1980s… “evaluative science”

Page 2 - © IPCRG 2007
2008

What this session will cover:

• What is meant by variation?
• Does it matter?
• How should it be analysed?
• What can be done by individuals?
• What can be done by IPCRG?

2008

What is meant by variation?

© IPCRG 2007

Patient
variation:
smoking
prevalence
eg 13-15 years

Data 2001 or later

Green: 30% and over
Blue 20%-29%

2008 Mackay J et al The Tobacco Atlas, 2nd ed 2006. American Cancer Society, UICC.

Patient
variation:
deaths from
tobacco use
More than 25% of
35-69 year old
males + 20% of
females living above
the lines will die
from tobacco use

2008 Mackay J et al The Tobacco Atlas, 2nd ed 2006. American Cancer Society, UICC. Also

Variation male/female; incidence and outcome: lung
cancer in Europe
Age-standardised cancer incidence rates Age-standardised (European)
per 100,000 population, lung cancer, by mortality rates, lung cancer, EU
sex, EU, 2006 countries, 2002 estimates

2008 http://info.cancerresearchuk.org/cancerstats/types/lung/mortality/

Variation in smoking cessation rates
Good news in UK - that most deprived areas doing better
but:

• Nearly 50% of health orgs in deprived areas were “excellent” vs
20% in affluent areas
• Those scoring “excellent” most likely to hit quit rate target (87%
did)
• Those with extra resources did better
• Those performing poorly not working with other agencies
• Most not consulting with public about how to do it
• Health orgs not developing expertise of own staff

2008 http://www.healthcarecommission.org.uk

Dartmouth Atlas: variation in preference-
sensitive care, and in effective care

2008
http://www.dartmouthatlas.org/atlases/atlas_series.shtm

Dartmouth Atlas: Variation in
supply-sensitive care
• Hospitalisations for medical conditions
• Stays in intensive care units
• Visits to physicians
• Referrals to specialists

2008 Wennburg J. Unwarranted variations in healthcare delivery: implications for academic medical centres BMJ. 2002 October 26;

Show asthma or COPD variation

2008

Further analysis to inform PCT work programme (Havering PCT)

National Prevalence PCT Prevalence
120 for COPD (1%) for COPD (1.4%)

High achievement High achievement in COPD Indicators
Low prevalence vs. PCT and National High prevalence vs. PCT and National

100
% Diagnosis Confirmed by Spirometry

80

60
50% achievement
in COPD Indicator 3

40

20

Low Prevalence High Prevalence vs PCT and National
Low Achievement Low achievement in COPD Indicators
0
0.0% 0.4% 0.8% 1.2% 1.6% 2.0%
2008
% COPD Prevalence

Unwarranted and warranted sources of practice variation
Unwarranted Warranted
• Variable access to resources • Clinical differences among
and expertise patients
• Insufficient research • Variable risk attitudes
• Unfounded enthusiasm
• Variable preferences
• Parochial perspectives among health outcomes
• Faulty interpretation
• Variable willingness to
• Poor information flow make time trade-offs
• Poor communication
• Variable tolerance for
• Role confusion decision responsibility
• Variable coping styles
Decreasingly knowledge- Increasingly patient-
based centered
2008 Prof Al Mulley, Foundation for Informed Medical Decision Making www.fidm.org

There is a gap between
what we know and what
we do…and, particularly
in low income
countries, there is also a
gap between what we
need and what is known
2008
Prof Don Berwick www.ihi.org

Underuse, overuse and misuse?
Active symptom intensive or acute
management in care for people with
end stages of COPD
COPD Increased use of
LABA/ICS combinations
for asthma

In UK, in 2005 574 different
head and socket combinations
used in hip replacement ops Use of inhaled
England and Wales…impossible medication for
to get meaningful data or gain asthma in Asia
bulk purchase deals Pacific
2008

Why does it matter?

© IPCRG 2007

Why does it matter?

• We don‟t use all the science we know - use the
evidence to improve outcomes
• We could reduce health inequalities and achieve global
targets of EQUITY
• We should avoid unnecessary risks for patients and
• Use scarce resources efficiently and
• Improve self-management

2008

Patients are aware of the
inequity:
European Allergy, Asthma & COPD
Patients’ Sofia Declaration 2 June 2007
• Access to good, equal standards of care, no matter
where you live in Europe

• High standards of and access to patient &
professional education, information and new
knowledge

• Healthy, unpolluted air to breathe indoors and out

2008
European Federation of Allergy and Airways Diseases Patient‟s Association (EFA) www.efanet.org

Both “underuse
and overuse of
treatments are
rife in this and
most other
countries and
are enemies of
effective
healthcare” (UK
Chief Medical
Officer 2005)
2008

What’s relevance of UK to
anywhere else?
• Only 20% of cases of chronic disease occur in
high income countries
• 75% of smokers live in low or middle income
countries
• Next 20 years communicable disease is
predominant problem in low-and middle-income
countries but then
• Epidemic of chronic disease everywhere
• Will affect those in poverty most

2008 Ottmani S et al. Respiratory care in primary care services. A survey in 9 countries. WHO 2004. Quoted in Chronic Respiratory

The smoking epidemic
Male smokers Female smokers
Male deaths Female deaths
100 50

80 40

% of d ea ths du e t o sm o ki ng
% of sm okers am on g a du lts

60 30

40 20

20 10

Year
0 0
0 10 20 30 40 50 60 70 80 90 100

Stage I Stage II Stage III Stage IV
Sub-Saharan China, Japan, Eastern and W Europe,
Africa SE Asia, Southern Europe N America
Latin America, Australia
N Africa

2008 Adapted from Lopez AD, et al.. Tobacco Control 1994; 3: 242-247

Achieving equity is tough
Patients with low health literacy
• Have poorer health status
• Are at greater risk of hospitalisation and have longer length of stay
• Have higher rates of emergency admission
• Are less likely to adhere to plans and treatments
• Have more medication and treatment errors
• Have less knowledge of disease management and health promoting
behaviours
• Have decreased ability to communicate with HCPs and share decision-
making
• Are less able to make appropriate health decisions
• Make less use of preventive service
• Incur substantially higher healthcare costs

2008 Coulter and Ellins QEI review Chap 1Health literacy drawing on Ad Hoc Committee on Health Litera

but the evidence exists…
GP time Increase in
5-7 fold
quit rate
>5 mins
Intense
intervention

4 fold
2-5 mins Moderate intervention

<1 mins Brief intervention
3 fold

2 fold
A „no-smoking practice‟

2008 IPCRG: Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9

How is it analysed?

© IPCRG 2007

Statistical process control
•Shipman and Bristol
Royal Infirmary
enquiries in NHS
•Study variability of
performance over time
or between insitutions
or areas
•Powerful tools for
population health
surveillance
•Software available
•Define “control” limits
of variation beyond
which data points
worthy of investigation
2008
http://www.erpho.org.uk/viewResource.aspx?id=14882

4 sorts of variation (Bevan, UK)
Natural
Natural + common-cause Natural variation +
Eg patient‟s “special cause” eg 1st
age, gender, disease time exceptionally sick
etc child turns up at clinic
Common
cause =
Special
expected
cause =
within a
unusual,
stable Artificial + common Artificial + “special unexpected
process cause” eg Test results
or system cause: ordering
- that‟s different tests for the in wrong pile. Lost
“under paperwork. Wrong code.
same clinical
control”
presentation

Artificial = from systems we‟ve developed
2008 Bevan H. NHS Institute for Innovation and Improvement

Our reaction to data about our services

• The data are wrong

• The data are right but they are not a problem

• The data are right, it is a problem, but it’s not MY
problem

• The data are right, it is a problem, and it is my
problem

2008
Don Berwick, IHI

ICU ADMISSION
ICU admission
YES
YES NO
NO

1 (1) 2 (14)

YES

Comfort
Care 4 (34)
3 (1)
NO

2008

So we know what it is, and how it is
analysed, but so what?

© IPCRG 2007

Model for Improvement

What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?

Act Plan

Study Do

32
Page 32 - © IPCRG 2007 Institute of Healthcare Improvement

NHS Institute: the 19 ACS conditions: 19
conditions

UK:
Admissions
for “ACS
conditions”
account
for 6% -
13.2% of
total
hospital
costs

2008

Why? What is the root
cause, and how can this
change?
For what purpose do you do
things?

How do you think of
yourself? “I am..”

What‟s important? Why?

How do you/they do that?

What you do/communicate

Does where you are
help/hinder?

2008 Developed by Gregory Bateson, Enhanced by Robert Dilts

Checkland’s sensemaking questions:
• What stories do staff tell about their practice
• What roles are occupied in this practice?
• What is considered legitimate work?
• How do you define success?
• How has this practice responded to external
events in the past?
Examining response to change:
• How do perceptions of legitimate work affect
approaches to change?
• How are roles changing in the practice?

2008 Checkland K. B Understanding general practice:a conceptual framework developed from case studies in the UK NHS

The implications for change management in
primary care

• General practices/primary care offices are small
organisations
• Change needs to be bottom up and
• Is determined by PCP’s view of organisational reality
• Important factors for generating responses to change
included
o the story that the practice members told about their
practice,
o beliefs about what counted as legitimate work,
o the role played by the manager, and
o previous experiences of change.

2008

Identity:

Do you
identify a
Do you hierarchy?
regard
smoking
cessation Is your
as identity a
legitimate problem-
work for solver,
you? provider of
continuous
care, follower
of protocol?
2008

Behaviours and beliefs

“In early stages of the smoking pandemic, higher status
individuals like health professionals tend to exhibit
markedly higher smoking prevalence rates than general
population. In later stages..health professionals -
direct observers of the terrible health consequences,…
often quit smoking and initiate national tobacco-control
movements”

2008
WHO Tobacco Atlas

Beliefs: physician smoking (data available 2005)

41% and
above

57% of male
physician in
China are
smokers

2008 WHO Tobacco Atlas

So what does it mean for you, and
us?

© IPCRG 2007

What does this mean for practice?

Patient-side Clinician-side

• Use tools to • Pay attention to own beliefs
and identity
understand level of
• Use tools to identify patient‟s
knowledge, needs,
needs and beliefs
beliefs, identity
• Educate
• Share decisions • Apply the evidence
• Share decisions

2008

IHI chronic care

2008
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.

Addressing warranted and
unwarranted variation
Knowledge-Based Patient-Centered
• Manage all relevant knowledge and • Tailor evidence for individuals
expertise • Frame problems from the patient’s
o Access and critically appraise perspective
evidence
• Communicate options and probabilities
o Access and selectively use
of outcomes
expertise of colleagues
o Access and use guidelines and • Help patients to accurately imagine
other support when appropriate alternative futures
o Acknowledge uncertainty • Elicit and accommodate patients’
o Recognize uniqueness informed preferences
• Avoid over-learning and selective • Elicit motivation when needed
inattention; maintain
• Build patients’ confidence and affirm
context
their competence
• Communicate effectively
• Use patients’ experiences as a source
of knowledge
Unwarranted variation Warranted variation
2008 Prof Al Mulley, Foundation for Informed Medical Decision Making www.fidm.org

Segment patients

2008

Example of respiratory research on
segmentation
A-L Caress, K Beaver, K Luker, M Campbell and A
Woodcock. Involvement in treatment decisions: what
do adults with asthma want and what do they get?
Results of a cross sectional survey
categorized asthma patients into those who prefer -
- an active role
- collaborative role or
- passive role
at a time of routine care and during an acute phase of
their illness
+ (under diagnosed anxiety and depression)

2008
Thorax 2005;60;199-205

Use of different databases…
Mosaic groups:
• Postcode level data: Symbols of success - career
17 households professionals

• Refreshed yearly
Happy families - younger families
Ties of community - close-knit inner
• 54% of data from city
Census, 46% from Urban intelligence - educate,
young, single, transient
lifestyle data,
Welfare borderline
financial records,
Municipal dependency
survey data Blue collar enterprise
• Data linkage: health, Twilight subsistence
lifestyle, attitudes, Grey perspectives
crime, etc Rural isolation

2008

GARD: 3 segments in low
income countries
• In urban areas with high income +
settled, sedentary lifestyle
o High income, can afford diagnostics and treatments
o Government workers - reimbursed
o Industrial, agricultural, service sector workers -
reimbursed
• In urban areas with limited resources or jobless
OR in low income suburban or periurban areas
• Poor people in rural areas

2008
Global Alliance Against Respiratory Disease a comprehensive approach

Understand environment, beliefs

“ in your country
disclosure is
empowering…in mine,
I have to think who to
tell, even my family”

2008

Effective strategies: informing,educating
and involving patients
• Improve health literacy:
o Printed leaflets and health information packages
o Computer based and internet health information
o Targeted approaches to tackle low health literacy
o Targeted mass media campaigns
• Improve clinical decision making
o Patient decision aids
o Training in communication skills for HCPs
o Coaching and question prompts for patients

2008 Effectiveness of strategies for informing, educating and involving patients. Coulter A. Ellins J. BMJ

Effective strategies: informing,educating and
involving patients
• Improve self care
o Self management education
o Self monitoring and self adminstered treatment
o Self help groups and peer support
o Patient access to personal medical information
o Patient centred telecare
• Improve patient safety
o Information to help choose safe providers
o Patient involvement in infection control
o Encouraging adherence to treatment regimes
o Check records and care processes
o Patient reporting of adverse drug events

2008 Effectiveness of strategies for informing, educating and involving patients. Coulter A. Ellins J. BMJ 2007:335;24-27

The competition for public
attention:

2008

Dept Health: passive
smoking
Social marketing to
prevent illness UK
Dept Health, different
brands, different
messages, same goal CHF
charities:
“Artery”
campaign

Cancer
charities:
“light”
still has
same
2008
nicotine

Health coaching
o IHI testing
teamlets

o Health
Dialog
selling
“health
coaching” to
create co-
producers in
healthcare

2008 Ann Fam Med. 2007 Sep-Oct;5(5):457-61 Bodenheimer T, Laing BY

Education:
cardiothoracic
surgery UK

2008
http://heartsurgery.healthcarecommission.org.uk/Survival.aspx

Public expectation is more
informed: CABG surgery UK: one
hospital compared to others

2008
http://heartsurgery.healthcarecommission.org.uk/Survival.aspx

Public expectation is more
informed: CABG surgery UK: one
doctor compared to others

2008 http://heartsurgery.healthcarecommission.org.uk/Survival.aspx

Ideal process is for shared decision-
making where each offers value:

CLINICIAN PATIENT
• diagnosis • experience of illness
• disease aetiology • social circumstances
• prognosis • attitude to risk
• treatment options • values
• outcome probabilities • preferences

2008 Angela Coulter, Picker Institute

“Knowing is not enough. We must apply.”
Johann Wolfgang von Goethe

• We are not using all the science we know
• Individuals integrate the evidence into their own
practice in a piecemeal way rather than
systematically to avoid infringing clinical
autonomy So:
• Practise the science of medicine, consistently
• Practise the art of
medicine, together, altruistically

2008

Reliability science [René Amalberti IHI]

No limit on discretion Increasing safety margins

Excessive autonomy of actors Becoming team player
Agreeing to become
Craftmanship attitude
« equivalent actors »
Accepting the residual
Ego-centered safety protections, vertical conflicts risk
Accepting that
Loss of visibility of risk, freezing actions changes can be
destructive
Blood transfusion
Fatal Iatrogenic

No system beyond
adverse events Anesthesiology
ASA1

this point
Cardiac Surgery Medical risk (total)
Patient ASA 3-5
Himalaya Chartered Flight
mountaineering Civil Aviation

Microlight or Road Safety Railways (France)
helicopters spreading
activity Chemical Industry (total) Nuclear Industry

10-2 10-3 10-4 10-5 10-6 Fatal
Very unsafe Ultra safe Risk

NICE: how to change practice

2008 National Institute of Clinical Effectiveness. How to change practice. Dec 200 www.nice.org.uk

Disseminating innovations in health
care: 7 principles for managers
• Find sound innovations with these perceived attributes:
• Find and support innovators
• Invest in early adopters: they are the opinion leaders
• Make early adopter activity observable
• Trust and enable reinvention
• Create slack for change
• Lead by example

2008
Berwick D. Disseminating innovations in Health Care. JAMA 2003; 28:1969-1975

What does it mean for the IPCRG?

• Collaborate on real life research
• Support research and analytical techniques
• Disseminate knowledge to clinicians
• Disseminate knowledge to the public
• Create tools that can support concordance
o Elicit beliefs, identity of clinician and patient
o Support shared decision-making - decision aids
• Learn from each other

2008

Four areas of activity

Endorsement

Education

Research + Publications Promotion

2008

Primary Care Respiratory Journal

Medline listed
Primary care authors
Primary care editorial board
Primary care audience

2008

So what does this mean?
• Collect data to look for variation
• Analyse: warranted or unwarranted
• If unwarranted: common or special cause?
Misuse, underuse or overuse?
• Plan the intervention: seek beliefs, concerns, identity.
Consider segmentation. Apply the evidence
consistently.
• Aim to make shared decisions: be aware of personal
identity and beliefs too
• IPCRG will collaborate to provide:
research, publications, endorsement, education +
promotion
2008

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