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Mapping differences in care

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The AMA’s Health Financing and Economics Committee (HFEC) considered the issue of healthcare variation at its meeting on 10 October.

Members of the Medical Practice Committee joined the meeting to receive a briefing on the nation’s first Australian Atlas of Healthcare Variation, which is due to published by the Australian Commission on Safety and Quality in Health Care this month.

Associate Professor Anne Duggan, who chaired the committee advising the Commission on the Atlas, told the meeting its purpose was to inform the development of strategies, resources and tools to identify and reduce unwarranted health care variation, and to drive further investigation into variation at the local area level.

 The HFEC and its predecessor, the Economics and Workforce Committee, have had a longstanding interest in health care variation, particularly how it reflects the impact of healthcare financing and funding arrangements on the delivery of health care. These are both key terms of reference for the Committee.

In its first iteration, the Atlas will be in hard copy, though later editions may be published in an interactive online format. Internationally, this is not new ground. Both the United Kingdom and New Zealand have published their own atlases of health care variation.

At its simplest, health care variation relates to the gap between what is known to be effective, based on the best available evidence and research, and what actually happens in practice.

Of course, there may be good reasons for variation across areas. When these factors are taken into account, what is left is often referred to as unwarranted variation – differences that cannot be explained by patient factors including illness or medical need, or by the evidence-based medicine that should apply.

How should we, as clinicians, approach the issue of health care variation and the Atlas?

Clinicians have a direct interest in understanding variation in the health care they provide. Knowing the results of the care we provide, how well this meets patient needs, and how these results compare (fairly and accurately) with care for other patients in other locations and from other health care providers, is an inherent part of clinical care. This is essential information for delivering effective health care and for continuing improvement as part of clinical stewardship.

As clinicians, and with and on behalf of our patients, we clearly have the most direct interest in data on health care variation. If clinicians do not engage with this issue, what is assumed to be unwarranted variation, and the actions taken to address it, will be decided by others.

But engaging with the data doesn’t mean slavish acceptance. When publications such as the Atlas are released, our first responsibility is to carefully and critically consider the data. This is essential to determine what is warranted, as opposed to unwarranted, variation.

Members of the Committee said it was important to consider why particular areas have been selected, and whether they reflect preconceptions and existing agendas about variations.

It is also important to understand what data sets have been used to provide the health care data, and whether they have particular limitations that affect comparisons across areas, such as different treatment protocols or different approaches to providing services in or out of hospital.

It should also be recognised that atlases of health care variation are unlikely to address some important factors, such as how the preferences of patients can influence the nature and location of care provided.

Overall, the Atlas should serve as a conversation starter. The data it presents (taking into account necessary qualifications) should be used to explore the amount of, and possible reasons for, variation. That is, it should be used to help inform the start, but not the end, of the health care story.