Tuesday, 3 January 2012

Unwarranted variation: the engine of improvement

J. Allison Glover, a medical officer in the pre-World War II Department of Health is credited with identifying unwarranted variation by discovering that a child’s chances of undergoing tonsillectomy depending on which school they were attending. Glover examined the effects of overcrowding, poverty, bad housing and climate but concluded that the major source of variation was differences in the system of healthcare, in this case the medical opinion of the school health officer responsible for referral for surgery. We see similar variation today in the modality of renal replacement therapy across the country depending on the attitudes and philosophy of the kidney unit rather than the choice of patients.


Jack Wennberg, of the Dartmouth Atlas fame took that idea and 30 years later looked in detail at rates of a whole range of interventions in two Vermont towns. Jack found big variance in many procedures and interventions – but there was nothing to suggest that the underlying illness rates of the two populations were any different. Variance research was founded and with it the science of healthcare delivery.


The second addition of the NHS Atlas of Variation builds on this history and was published just before Christmas. It highlights a range of conditions across the whole spectrum of health and picks out acute kidney injury (AKI), rate of kidney transplantation from living donors and deceased donor transplant rates for close scrutiny.



Admissions attributed to AKI have been rising in recent years, possibly as a result of increased awareness, although the results of epidemiological studies show rising prevalence as well. The management of AKI is resource intensive, costing the NHS £600M per annum and adding 4.7 days to the mean length of stay. For PCTs in England the rate of admissions attributed to AKI for all emergency admissions to hospital ranged from 0.4 to 2.7 per thousand (a 7-fold variation). This degree of variation could reflect the distribution of AKI risk factors in the community, levels of awareness of AKI and the organisation and management of care for people who are acutely unwell. The Atlas team identify action for commissioners







  • To implement an acute care CQUIN (see NHS Kidney Care AKI resource pack)

  • To ensure that the AKI care pathway is identified in every setting where people with acute illness are managed.

  • To tackle AKI in QIPP plans.
For clinicians it is important to focus on improving the basic care of the acutely unwell including:


  • Recognising illness severity and deterioration

  • Prompt resuscitation

  • Timely management of infection and sepsis

  • Safe prescribing

  • Careful attention to hydration and nutrition.
For managers it is important to:


  • Implement an electronic system for AKI alerts in laboratory reporting systems

  • Audit AKI outcomes and quality of care

  • Implement the national confidential enquiry into patient outcome and death (NCEPOD recommendations on AKI)


The number of living donor transplants performed has increased markedly over the last 10 years and, despite a fall of 2% in living donor transplants in 2010-11, living donation represents more than 1/3 of the total kidney transplant programme, it’s integral to saving people’s lives. The overall rate of kidney transplant from living donors for England in 2010-11 was 16.5 pmp we need to make sure that this option is being explored early and offered widely to all those who can benefit from living donation.
The rate of kidney transplants from deceased donors per million population ranges from 14.7 to 29.2, a twofold variation.

One reason for variation is differences in regional demography, particularly the proportion of black and minority ethnic (BME) groups in the population who are three times more likely to need a kidney transplant but only 1.2% of people from the South Asian and 0.4% of people from the black communities have joined the organ donation register (ODR).

Commissioners and providers are encouraged to support the work in acute hospital and foundation trusts of donation committees, clinical leads in organ donation and specialist nurses for organ donation, all of whom are working to ensure that organ donation becomes a “usual” event. We also need to find better ways to engage with our local BME communities to raise the profile of kidney transplantation as was recently emphasised by the All Party Parliamentary Kidney Group at a reception at the Houses of Parliament .

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