View Abstract

A6846 - Measurement of Practice Pattern Variation in the Provision of Intensive Care: A Systematic Review
Author Block: R. Simmons-Beck1, N. Bosch1, A. J. Walkey2; 1Boston Medical Center, Boston, MA, United States, 2Pulm, Boston Univ School of Med, Boston, MA, United States.
Introduction: Health services research seeks to measure variation in practice in order to identify opportunities for practice improvement and to leverage variation to study observational comparative effectiveness. Although multiple studies examining practice variation during the provision of critical care have been published, the extent of routine ICU practice variation is unclear, as is the extent to which methods for quantifying practice variation have been harmonized across studies. We sought to systematically review reports of practice variation in critical care. Methods: We searched Pubmed using medical subject headings and natural language text to identify articles published between 2000 and 2017 that measured physician practice variation among adult ICU patients. We included studies that identified a statistical summary measure of variation, including mean, median, interquartile range, median odds-ratio, intraclass correlation, etc. Studies were excluded if there was no direct measure of patient care/intervention (e.g. surveys of physician opinions). We collected data on study design, statistical measures of variation, modeling strategy (e.g., fixed effects vs. random effects models), type of intervention studied, and whether risk adjustment was performed. Results: Of the 240 articles evaluated, 40 met inclusion criteria and were analyzed. 50% of evaluated studies used exclusively descriptive measures (frequencies, means, medians and percentages) of variation. 45% of all articles included did not use risk adjustment in estimates of variation and 60% did not account for hospital or physician clustering in measuring variation. Only 16 studies used measures of variation derived from hierarchical random effects models. Only one study used median odds ratio to summarize practice pattern variation, as such we were unable to pool data. Conclusions: Measurement of variation of clinical practice in the ICU is heterogeneous and the use of multilevel models for measuring inter-hospital and inter-physician variability is low. This heterogeneity may threaten the ability to target variation to improve care. Future work is needed to better standardize and harmonize the measurement of practice variation in critical care.