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Strategies for Reducing Regional Variation in the Use of Surgery: A Systematic Review

Reames, Bradley N. MD, MS*,†; Shubeck, Sarah P. MD; Birkmeyer, John D. MD*,†

doi: 10.1097/SLA.0000000000000248

Objective: To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

Background: The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

Methods: Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

Results: A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

Conclusions: Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

Supplemental Digital Content is Available in the Text.We performed a systematic review of practice guidelines and decision aids to better understand the effectiveness of these strategies to reduce regional variation in the use of surgery.

*Center for Healthcare Outcomes & Policy; and

Department of Surgery, University of Michigan, Ann Arbor, MI.

Reprints: Bradley N. Reames, MD, MS, Center for Healthcare Outcomes & Policy, University of Michigan, Bldg 16, Room 100N-08, 2800 Plymouth Rd, Ann Arbor, MI 48109. E-mail:

Disclosure: Supported by the National Cancer Institute grant (5-T32-CA-009672-22) (Dr Reames) and the National Institute on Aging grant (5-P01-AG-019783-10) (Dr Birkmeyer). These funding sources had no involvement in the manuscript herein. Dr Reames and Dr Shubeck have no conflicts of interest or disclosures related to the content of the manuscript. Dr Birkmeyer is Chief Scientific Officer and has an equity interest in ArborMetrix, Inc, which provides software and analytics for measuring hospital quality and efficiency. The company had no role in this study.

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© 2014 by Lippincott Williams & Wilkins.