Al Mulley: reducing unwarranted variations

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  • Posted:Wednesday 14 September 2011

Al Mulley, Director of the Dartmouth Center for Health Care Delivery Science and Visiting Fellow here at the Fund, gives an insight into his work around health care variations in the US.  

This was part of the 2011 conference: Reducing unwarranted variations in health care, which looked at patterns of variations, how they can support health professionals to meet the QIPP challenge of £20 billion efficiency savings by 2014/15 and how to provide the most clinical and cost effective interventions.


Elizabeth Evans

Comment date
24 September 2011
An interesting American perspective. In the UK patients don't get to be offered operations until they have been referred by GPs, so it is interesting to look at the range of variation amongst GPs in the same locality with the sane training and background. GPs on our area had a referral rate to Orthopaedics which varied 10 fold, There was also a considerable increase from year to year without increase in the epidemiology of the diseases concerned (hip osteoarthritis for example) nor improved methods of treating such conditions.The referral variation reduced only when GPs and Consultant surgeons were encouraged to look at what was referred, then a consensus developed on what should be referred, There was also a significant absolute reduction compared with other areas where an increase continued. The surgeons involved were those who were most concerned with quality and cost effectiveness, and they found themselves opposed by consultants who really just wanted to increase their departments output and prestige. GPs were incentivised to look at the quality of referrals and to use guidelines ,more effctively,. We consdered that the main reason for the huge varaiion was that there was no feedback at all to the GPs on the results of the referral, what the patient thpught of it and most of all what their peers thought of the referral. In addition GPs are bombarded with publicity for more and opre active treatment by surgeons when a much simpler answer to their problem might be available through a physiotherapist for example.

Elizabeth Evans

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