Elsevier

The Lancet

Volume 382, Issue 9898, 28 September–4 October 2013, Pages 1130-1139
The Lancet

Series
Strategies to reduce variation in the use of surgery

https://doi.org/10.1016/S0140-6736(13)61216-7Get rights and content

Summary

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

Introduction

Why should we try to reduce variation in surgical provision? The motivations and opinions of doctors often have a stronger effect on surgery rates than do disease patterns or scientific evidence of benefit.1 Does this variation matter and, if it does, can it be changed? There are persuasive ethical and economic arguments for control of variation in surgery rates. The scale of variation and the number of people affected suggests enormous potential to reduce avoidable morbidity and mortality and unnecessary use of resources. Patient autonomy should, in theory, be enhanced if appropriate surgery is available, but patients can demand surgery when there is no evidence for its benefit, and avoid surgery when it would help them; patient autonomy might actually contribute to variation. In this Series paper we assume that decreases in variation of provision that are not driven by need or evidence are desirable. We consider how such unwarranted variation can be identified, and what evidence exists about the effectiveness of potential strategies for its reduction.

Section snippets

What constitutes unwarranted variation?

Any attempt to reduce variation depends first on the identification of variations that are truly unwarranted, but this assessment can be difficult.1 Clinical guidelines are generally drafted by representative expert groups, whose interpretation of the evidence is understandably framed to include the majority of present practice in their professional community, leaving substantial leeway for individual judgment.

Key messages

  • Very little research has assessed methods to reduce

Patient pathway

The patient pathway for assessment and treatment with surgery offers several steps in which unwarranted variation could occur, or could be controlled (figure 1).1, 22, 23 Interventions aimed at the decision pathway to surgery broadly fall into four categories, all of which are directed at increasing the uptake of evidence-based care: effect of evidence on the provision of sugery for specific disorders, improvements in dissemination and uptake of existing evidence by clinicians, feedback on

Background

Organisations that have to make strategic decisions about the provision of health services to a population usually try to adopt a generic approach and avoid regulating provision for specific treatments or disorders. These organisations include hospital groups that contract with governments or insurers to provide surgical services for particular populations, groups, or regions, and agree a tariff and expected overall activity rate. This method is clearly efficient for the avoidance of many

Conclusions

In an international context, variations in surgery rates largely result from huge degrees of underprovision in low-income countries with underdeveloped health services. Uneven development of infrastructure and distribution of workforce, with a substantial rural–urban geographical disparity in resources, is a common underlying difficulty. However, in low-income countries surgical overprovision can occur in wealthy or privileged groups. Resolution of gross within-country disparities in access to

Search strategy and selection criteria

The interventions we chose to study were based on preliminary informal searches, discussions at a meeting at Balliol College, Oxford, UK (appendix), and consultations with experts in the discipline of surgical variation. We searched Medline up to Oct 31, 2012, for articles on the effects of interventions on surgery rates in specified specialties or disorders, with the use of a range of keywords and MeSH terms. The interventions were divided into nine topics within which 20 searches were

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