Clinical Practice Guidelines Reduce Geographic Variation in the Surgical Suite

Surgical Rounds®, March 2014,

Depending on where patients live, their likelihood of undergoing surgical procedures can vary 3- to 10-fold.

Depending on where patients live, their likelihood of undergoing surgical procedures can vary 3- to 10-fold.

Such wide variation raises questions about the appropriateness of interventions and their associated costs, as well as indicates that some patients are not receiving important surgical care, while others are receiving unnecessary procedures. Although no consensus has been reached, some experts believe relying on clinical practice guidelines can reduce geographic variation.

The April 2014 issue of Annals of Surgery includes a study that examined the effect of practice guidelines and decision aids on surgery rates and regional variation. To do so, a team of physicians from the University of Michigan reviewed studies that evaluated the influence of several tools: clinical practice guidelines, consensus statements, shared decision-making and decision aids for patients, and provider feedback of comparative utilization.

Of the 1,946 studies identified, 27 met inclusion criteria for the final review, though none of them were randomized controlled trials. Twelve studies addressed guideline implementation, with 6 reporting a significant effect. When the researchers examined overall population-based rates, they found mixed effects. Studies that were confined to procedural choices described at least small increases in use of guideline-recommended therapy. Although only 5 studies in total looked at regional variation, 3 of them reported a significant reduction in regional variation after guideline dissemination.

Of the 15 studies examining decision aids, one-third documented significant effects, and most reported decreases in population-based procedure rates. While decision aids appeared to sway patients to choose less invasive procedures more often, their effect on regional variation were unclear.

Similar to previous studies that suggested explicit clinical practice guidelines can effectively improve patient care, this study showed guidelines and decision aids can reduce geographic variation and subsequently improve care. Since expanding the documents’ roles will require clinicians to eliminate implementation barriers, the authors said healthcare organizations must recognize and address difficulties with changing the current practice model, practitioner resistance, and lack of trust in evidence or research. They should also encourage guideline creators to address the most confusing clinical questions and eliminate information that contradicts with other expert opinions.