VARIATION AND QUALITY

The initial descriptions of variation in medical care have led to and fuelled international concerns about quality of care. Although differences are expected, particularly when there is clinical uncertainty, the extent of variation in many diagnostic and therapeutic manoeuvres is concerning. Much of the National Service Framework is focused on reducing variation and improving quality. Sawczenko and colleagues found extensive variation in the initial care of 739 children diagnosed with inflammatory bowel disease between June, 1998 and June, 1999. Two variables—the size of the “reporting” centre (number of new cases during the study year) and the type of specialist involved (paediatric versus adult gastroenterologist)—account for much of the variation. These findings are consistent with the published literature in this area. In general, quality improves as volume increases, although there is likely a plateau effect for most medical conditions. Secondly, physician discipline (generalist versus specialist, adult versus paediatric) impacts on diagnostic and therapeutic decisions. The struggle for most health care systems will be linking patients …