Medical practice variation: shifting the paradigm toward the clinicians’ perspective
Authors:   , Vink Maarten Dirk Hendrik 
Published: July 2024

In the first study (Chapter 2), we conducted a scoping review of studies into medical practice variation in cesarean section rates between individuals, institutions, and geographic areas. We assessed study design on the data sources used, study population selection procedure, aggregation level for analysis, maternal and neonatal outcomes, case-mix correction, and determinants of practice variation. Less than one-third of the studies performed case-mix correction, and aggregation was mostly at the hospital level. Maternal and neonatal outcomes were considered in fewer than one-fifth of the studies. Significant variation was observed in cesarean rates across areas and hospitals. Future research should better account for patient characteristics and provide feedback on clinical performance using lower aggregation levels to facilitate use in Audit and Feedback (A&F) cycles.

In the second study (Chapter 3), we analyzed Dutch General Practitioners (GPs) experiences with the Primary Care Practice Report (PCPR). Using qualitative methods and semi-structured interviews, we found that GPs perceived the PCPR's feedback as not clinically meaningful; the data were not recent, individualized, or reliable; performance comparators offered insufficient guidance to improve clinical performance; results were not discussed with peers; and definitions and visuals lacked clarity. GPs desired more specific feedback related to clinical outcomes and actionable data on disease patterns and interventions.

The third study (Chapter 4) examined healthcare substitution for intrauterine device (IUD) insertions from secondary to primary care in the Netherlands using claims data from 2016-2020. We found that 74% of IUDs were inserted in primary care, with regional variation from 58% to 82%. Primary care providers performed fewer follow-up ultrasounds and reinsertions than secondary care providers. This study highlighted significant regional variation and suggested that better collaboration among healthcare providers could enhance care substitution, reducing costs and improving patient care.

In the fourth study (Chapter 5), we assessed whether hysterectomy rates for women with bleeding disorders or fibroids were substituted by less invasive techniques. Our study suggests that, except perhaps for the embolization technique, at the regional level, minimally invasive techniques are used in daily practice as additional methods and not solely as a substitute for hysterectomy. Our results also provide regional insights for healthcare professionals about the surgical techniques employed for hysterectomy.

The fifth study (Chapter 6) analyzed variation in the stepped-care model for women with idiopathic heavy menstrual bleeding using Dutch insurance data. We found substantial variation in treatment approaches across hospitals, indicating room for improvement in implementing less invasive treatments. Our findings suggest that women often receive suboptimal care, neglecting least invasive options initially.

In the sixth study (Chapter 7), we aimed to identify guideline deviations in cervical cancer screening in Dutch hospitals by linking insurance and pathology data. We created quality indicators to evaluate compliance with the management and treatment outcomes of cervical pre-malignancies. We found instances of overtreatment and undertreatment, consistent with existing literature. Providing hospital-level data to healthcare professionals can enhance feedback utilization and improve care quality.

The final study (Chapter 8) involved interviewing key stakeholders to identify measures to reduce unwarranted medical practice variation. We propose four strategic measures to enhance the integration of scientific evidence into daily medical practice:
1.	Provide A&F data to healthcare professionals
2.	Establish a clear understanding of the impact of implementing healthcare evaluation studies and assure healthcare professionals that practical challenges related to implementation are being actively addressed.
3.	Comprehensive agreements should be established concerning the financial consequences of novel clinical practices if the adoption of new scientific evidence carries potential financial implications
4.	Institute supplementary national measures when changes in clinical behavior among healthcare professionals lag behind the required standards despite the aforementioned measures.