Neither Richards nor Lilford make a worthy case, since both fail to
address the relevance of the term "unexplained".
Richards suggests that deviation from evidenced practice should be
detected as 'special variation' and rooted out. And 'Common variation' is
a term that begs so many questions. He has a touching faith in
"statistical process control". For example, he homes in on variation in
QOF exception rates, and ( typically ) turns his attention to High-
excepters - "PCTs have a mechanism for investigating practices with
unusually high rates of exception reporting and they should use it." He
does not explain why low-excepters, or indeed 'average-excpeters' should
not also be investigated. Statistical deviation of practice rates has no
demonstrated relevance. Either this patient should be excepted or should
not, and no other patients are relevant. An acceptable EXPLANATION for
variation is all that matters. The same is true for prescribing rates.
I regularly enjoy taking my prescribing advisers to task, by pointing out
my Simvastatin rates are easily the highest in the county. I contest
that I am prescribing evidence-based medicine, and other GPs are not
keeping up with my pace. Why is it that 'prescribing quality' advisers
pay such scant attention to low-rate prescribers? Could it be that they
have not triggered the 'Cost' statistical process control ?? Similarly, a
quoted statistical norm suggests a preventer-inhaler rate should be half
the reliever-rate. But the only real questions are " have my patients got
Asthma, and are their treatments working ? ".
Lilford began well by presuming that patient choice and evidence-
based differences constituted a sufficient explanation. But where
evidence was lacking, he argued that various opinions and actions were
acceptable. Isn't such variation therefore 'explained' ?
Nobody has actually addressed 'unexplained variation'. I venture to
suggest it is not desirable, without first explaining why it is harmful..
Rapid Response:
Unexplained ?
Neither Richards nor Lilford make a worthy case, since both fail to
address the relevance of the term "unexplained".
Richards suggests that deviation from evidenced practice should be
detected as 'special variation' and rooted out. And 'Common variation' is
a term that begs so many questions. He has a touching faith in
"statistical process control". For example, he homes in on variation in
QOF exception rates, and ( typically ) turns his attention to High-
excepters - "PCTs have a mechanism for investigating practices with
unusually high rates of exception reporting and they should use it." He
does not explain why low-excepters, or indeed 'average-excpeters' should
not also be investigated. Statistical deviation of practice rates has no
demonstrated relevance. Either this patient should be excepted or should
not, and no other patients are relevant. An acceptable EXPLANATION for
variation is all that matters. The same is true for prescribing rates.
I regularly enjoy taking my prescribing advisers to task, by pointing out
my Simvastatin rates are easily the highest in the county. I contest
that I am prescribing evidence-based medicine, and other GPs are not
keeping up with my pace. Why is it that 'prescribing quality' advisers
pay such scant attention to low-rate prescribers? Could it be that they
have not triggered the 'Cost' statistical process control ?? Similarly, a
quoted statistical norm suggests a preventer-inhaler rate should be half
the reliever-rate. But the only real questions are " have my patients got
Asthma, and are their treatments working ? ".
Lilford began well by presuming that patient choice and evidence-
based differences constituted a sufficient explanation. But where
evidence was lacking, he argued that various opinions and actions were
acceptable. Isn't such variation therefore 'explained' ?
Nobody has actually addressed 'unexplained variation'. I venture to
suggest it is not desirable, without first explaining why it is harmful..
Acceptable explanation is what counts !
Competing interests:
None declared
Competing interests: No competing interests