Academic journal article Australian Health Review

Screening for Important Unwarranted Variation in Clinical Practice: A Triple-Test of Processes of Care, Costs and Patient Outcomes

Academic journal article Australian Health Review

Screening for Important Unwarranted Variation in Clinical Practice: A Triple-Test of Processes of Care, Costs and Patient Outcomes

Article excerpt


Variation in clinical practice remains a widely acknowledged barrier to the equitable and efficient provision of health care.1 Some variation is warranted, reflecting heterogeneity in the clinical symptoms and preferences of individual patients, but there is also unwarranted variation, which results in the inefficient use of scarce healthcare resources. Unwarranted variation has been broadly defined as reflecting 'the limits of professional knowledge and failures in its application' .2 Quality improvement to reduce unwarranted variation in clinical practice is not a trivial task,3 and so healthcare providers should focus on priority areas, in which expected net benefits are greatest.

The identification of important and unwarranted variation in clinical practice necessitates some form of comparative assessment of hospital performance. Australian Commission on Safety and Quality in HealthCare (ACSQHC) has published Clinical Care Standards for a range of key clinical areas,4 with associated sets of process indicators to assist quality improvement. A limitation of process indicators is the focus on components of care pathways that are measurable. Important aspects of a care pathway may not be measurable because of data system limitations, as well as because of the non-deterministic and qualitative nature of the processes being measured.5 This means process indicators alone provide only a partial analysis of quality.

The ACSQHC is also promoting the use of hospital mortality indicators as a screening tool to identify high and low performing areas of clinical activity.6 Lilford et al. cite the poor correlation between outcomes and quality7 while noting that the problems associated with outcome measures are reduced when they are not used to judge performance, but to inform improvement in a non-punitive manner.

Alternatively, activity-based funding aims to inform healthcare improvements through analyses of cost differences in the provision of similar services. The Independent Hospital Pricing Authority is developing methods to incorporate measures of quality within an activity-based funding framework, but currently no adjustments are made for safety and quality.8

As the above examples indicate, the alternative forms of performance measurement are generally considered in isolation. This paper presents a case study application of a triple test to screen for important variations in processes of care, costs and outcomes for patients presenting with symptoms suggestive of acute coronary syndromes (ACS) at four large public hospitals in South Australia (SA).


Routinely collected hospital data were used to inform comparative analyses of processes of care, costs and outcomes for patients presenting at the emergency department (ED) with symptoms suggestive of ACS. The following sections describe the definition of the eligible population, the data sources and the data analysis methods.

Eligible population

The eligible population comprised all patients attending the ED of one of the four main public hospitals in SA in the year to 30 June 2010 with an ED diagnosis of either chest pain (International Classifications of Diseases (ICD)-10 code R07), unstable angina (ICD-10 code I20), or myocardial infarction (MI; ICD-10 code I21) and who received at least one troponin assay (a diagnostic indicator of cardiac muscle injury) during their hospital episode.

Data sources

The four study hospitals each maintain a suite of local data warehouses containing comprehensive patient-level information that describes key procedures, pathology test results, movement between hospital departments and wards etc., as well as automated links to population-based mortality data. These local systems have comparable nomenclature and collection practices, and are collated by the state health department in the form of a single, state-wide repository.

Separate administrative data, submitted to the state health department for every in-patient separation at all public and private SA hospitals, were available from 2003 to June 2011. …

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