The Trouble With Variation

Variation is the enemy of highly reliable healthcare.
This was the crux of one of my favorite articles of the past couple years, Dr. Atul Gawande’s “Big Med,” which appeared in The New Yorker. It was also the leading topic of discussion at the National Center for Healthcare Leadership’s 2013 Human Capital Investment Conference, which took place earlier this week in Chicago.
Keynote speaker Marty Makary, MD, an associate professor of surgery at Johns Hopkins School of Medicine in Baltimore and author of the book “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” called variation the “unspoken” problem of healthcare. To be sure, in the past few years, the concept of reducing variation has gained a higher profile, but the amount of variation in healthcare remains staggering.
Reducing variation is a concept that makes sense to most clinicians; most patients will benefit from care that is evidence-based and follows clinical protocols, yet getting physicians to agree on those protocols, and then adhere to them, can be incredibly challenging and time consuming.
Certainly, the idea of removing all variation in healthcare delivery is overwhelming; however, starting with a single episode of care can make the challenge less daunting. At the conference, Dr. Makary shared a powerful example to illustrate the problem of variation. Becker’s Hospital Review Managing Editor, who attended with me, explains:
Back when he was a resident, Dr. Makary saw two physicians perform separate colonoscopies, in which they discovered polyps in their respective patients. Each, however, went about removing the polyp in a different way — one via endoscopic surgery, another through open surgery. Despite having the resources and expertise to perform the procedure endoscopically, the physician who decided on surgery said his reason was a simple one: “That’s how I like to do it.”
The surgical method obviously involves more pain and scarring for patients, along with a higher rate of infection. The likely reason patients agree to undergo surgery when they could have a polyp removed endoscopically is they simply do not know better. “It’s [about] ‘how I like to do it.’ It’s a problem where we desperately need some transparency and accountability,” said Dr. Makary.

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By: Staff

In this example, two patients have roughly the same size polyp (about the size of a golf ball, according to Dr. Makary). One has is removed during colonoscopy and goes home that day. The other had to go through open surgery, a hospital stay, painful wound dressing changes, and his care was much more costly.


In this single example, the cost and quality potential for just the one patient is huge. To extrapolate that to all colonoscopy patients with a polyp in that single health system would result in huge savings, not to mention if it could be applied to all similar patients in the country. And that’s just for one single clinical presentation!


Last week I interviewed David Ballard, MD, MSPH, PhD, the chief quality officer of Baylor Health Care System. He shared with me the results of a quality improvement project to reduce variation in heart failure order sets. The health system, he explained, originally set out to reduce the variation simply to make nurses more efficient. There were more than 60 order sets used, and a single nurse on the heart failure floor might have 10 patients with 10 different order sets. With support from the health system, a group of multidisciplinary clinicians worked to develop a single, evidence-based order set. After it was rolled out to the physicians, the leaders of the department noticed something unexpected: cost and mortality decreased. They analyzed the numbers and found that if their successes were translated to all heart failure patients in the U.S., the savings could reach $2 billion and save 15,000 lives.


Reducing variation just may be the key to improving healthcare delivery in our country. But it can’t be done without transparency and accountability. To illustrate, Dr. Makary offered another example: There’s a guideline during colonoscopies that withdrawal of the scope should last six minutes. Any time shorter than that could lead to missed polyps, according to the medical research. Well-known gastroenterologist Douglas Rex, MD, performed a study where he videotaped GI doctors performing colonoscopies. The withdrawal times varied widely, from well under to well over six minutes. Then he told them he would be watching them. Guess what happened? Withdrawal times were all right around six minutes. The only thing that changed was knowing they were being observed.


Reducing variability and thereby improving quality throughout a healthcare delivery system demands transparency and accountability. While most physicians want the best for their patients, there are a million competing demands and reasons that may lead them, from time to time, to provide care that falls short of recommended guidelines. This chance can be eliminated though, when they know there are mechanisms in place that holds them accountable.

 

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