• Jane C Weeks, Hajime Uno, Nathan Taback, Gladys Ting, Angel Cronin, Thomas A D'Amico, Jonathan W Friedberg, and Deborah Schrag.
• Ann. Intern. Med. 2014 Jul 1; 161 (1): 203020-30.

BackgroundWhen clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected.ObjectiveTo systematically assess interinstitutional variation in management decisions for 4 common types of cancer.DesignMulti-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011.Setting18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network.Patients25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma.MeasurementsInterinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions.ResultsInterinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%.LimitationPhysician identifiers were unavailable, and results may not generalize outside of major cancer centers.ConclusionThe substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development.Primary Funding SourceNational Cancer Institute and National Comprehensive Cancer Network.

13 keywords...

hide…