Health care delivery systems and health care leaders globally are facing huge shifts in clinical services following the COVID-19 pandemic. Societal closedown has led to a decline both in acute and elective services, and hospitals have restructured services in order to manage patients with suspected COVID-19. Staff-fatigue and hospitals not designed for cohort isolation may lead to limited bed-capacity (1). Even if the number of patients admitted with COVID-19 declines, hospitals need to take preventive measures and manage patients’ anxiety for exposure to infections in hospital environments. In the post-COVID-19 era, hospitals have to prepare for possible new waves of COVID-19, while also focusing on re-establishing normal activity and managing waiting list backlogs.
Data from several countries, including Norway, have demonstrated a significant difference in backlogs between different clinical specialties. Within some specialities, hospitals have compensated for the decline in physical consultations with an impressive increase in the use of digital consultation platforms, including the use of telephone, video and digital conferencing systems. In other specialities, typically ear, nose and throat (ENT), ophthalmology, orthopaedic surgery and gastroenterology upper-and lower gastrointestinal endoscopies, almost half of the backlog consists of patients waiting for diagnostic- or therapeutic procedures requiring physical consultations.
Since William A. Guy at King’s College described variation in hospital and prison mortality in London in 1867 (2), numerous studies have been published on variation in health care. The Agency for Clinical Innovation in New South Wales, Australia, has defined unwarranted variation as “variation that cannot be explained by the condition or the preference of the patient and that can only be explained by differences in health system performance” (3). During the last decade, there has been an increasing attention on overdiagnosis and overtreatment (4). Health atlases have documented these phenomena, demonstrating significant regional variations in utilization rates and outcome measures. There is a growing consensus that unwarranted variation in health care needs to identified and reduced to avoid that providers expose patients to unnecessary and low value care with subsequent risk of adverse events. Can lessons from pre-COVID-19 efforts to reduce unwarranted variation inform leaders and specialist in planning and monitoring the use of the available hospital capacity in the post-COVID-19 era?
John E. Wenneberg, a pioneer and leading researcher of unwarranted variation, has highlighted three categories of clinical care (5): Effective care, preference sensitive care, and supply sensitive care.
- Effective care represents well-documented services. Patients who are eligible for these services should receive them, and failure to provide services represents underuse.
- Preference sensitive care represents services where two or more medically acceptable options exist and choice should depend on patient preferences. Research and health atlases has shown that utilisation and treatment patterns vary geographically. For preference sensitive care, patient involvement and shared decision-making is key.
- Supply sensitive care is a perplexing category because medical evidence plays a minor role in determining the frequency of the use of these services. Examples of unwarranted variation could be the amount of diagnostic tests and the frequency of consultations, referrals to medical specialists, hospitalisations, and stays in intensive care units.
Several initiatives have been launched to reduce the volume of health care services categorized as low value care such as overuse, underuse, inappropriate use and unnecessary care, so far they seem to have had limited effect. Still, we believe that we can use insights from the field of unwarranted variation to facilitate dialogues with consumers, medical specialists, insurers and policymakers to stimulate health care leaders to lead wisely in the post-COVID-19 era. A first priority should be to make use of available capacity and to target backlogs focusing on patients with the highest needs. Further, it will be interesting to see if the disruption and transformation caused by COVID-19 may have long-term consequences for the efforts to reduce unwarranted variation in the new normality of future health care.
- Edwards N. Here to stay? How the NHS will have to learn to live with coronavirus. Discussion paper, Nuffield Trust, 2020. https://www.nuffieldtrust.org.uk/resource/here-to-stay-how-the-nhs-will-have-to-learn-to-live-with-coronavirus
- Guy WA. On the mortality of London hospitals: and incidentally on the deaths in the prisons and public institutions of the metropolis. J Royal Stat Soc 1867; 30: 293-322. https://www.jstor.org/stable/2338513
- Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L. Addressing unwarranted clinical variation: a rapid review of current evidence. J Eval Clini Pract 2019; 25: 53-65. https://doi.org/10.1111/jep.12930
- Armstrong NOverdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. BMJ Qual Saf 2018;27:571-5. http://dx.doi.org/10.1136/bmjqs-2017-007571
- Wennberg JE. Time to tackle unwarranted variations in practice. BMJ 2011; 342: d1513. https://doi.org/10.1136/bmj.d1513
Dr. Ole Tjomsland
Dr. Ole Tjomsland is a specialist in thoracic surgery and project director at The South-Eastern Norway Regional Health Authority, Norway.
Dr. Jan Frich
Dr. Jan Frich is a specialist in neurology, deputy-CEO and chief medical officer at The South-Eastern Norway Regional Health Authority, Norway, and professor at University of Oslo, Norway.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.