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Review
. 2025 May 1;142(5):793-805.
doi: 10.1097/ALN.0000000000005395. Epub 2025 Apr 8.

Accounting for Healthcare Structures When Measuring Variation in Care

Douglas A Colquhoun  1 , Allison M Janda  1 , Graciela Mentz  1 , Clark A Fisher  2 , Robert B Schonberger  2 , Nirav Shah  1 , Sachin Kheterpal  1 , Michael R Mathis  1
Affiliations
Review

Accounting for Healthcare Structures When Measuring Variation in Care

Douglas A Colquhoun et al. Anesthesiology. .

Abstract

Health services research frequently focuses on variation in the structure, process, and outcomes of clinical care. Robust approaches for detection and attribution of variation are foundational to both quality improvement and outcomes research. Describing care in structured healthcare systems across hospitals in which clinicians work to provide care for patients as a multileveled structure allows the impact of organization on practice and outcome to be ascertained. Mixed-effect statistical models can describe both the partitioning of variation among levels of these structures and by inclusion of explanatory variables the valid estimation of the features of health systems, clinicians, or patients, with observed differences in processes or patient outcomes. In this Readers' Toolbox, the authors describe the rationale for considering healthcare structures when assessing clinical practice, outcomes, and sources of variation. They describe statistical considerations and methods for the estimation of analysis of structured data and assessment of variance.

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Conflict of interest statement

Drs Colquhoun, Mentz, Kheterpal declare past support from Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., (Rahway, New Jersey) paid to the University of Michigan unrelated to presented work. Dr Colquhoun reports receiving an honorarium from Medscape, Inc. and research support paid to the University of Michigan from Chiesi, USA (Cary, North Carolina) and GE Healthcare (Chicago, Illinois) unrelated to this present work. Dr. Janda has received research support paid to the University of Michigan from BioIntelliSense, Inc (Golden, Colorado) and Haisco-USA Pharmaceuticals, Inc (Bridgewater, New Jersey) unrelated to this present work. Dr. Mathis has received research support paid to the University of Michigan from Chiesi, USA (Cary, North Carolina) unrelated to this present work. Dr Shah reports research support paid to the University of Michigan from Patient-Centered Outcomes Research Institute (PCORI) (Washington, DC), Blue Cross Blue Shield of Michigan (Detroit, MI), Edwards Lifesciences (Irvine, CA) and Apple (Cupertino, CA) unrelated to the current work. Dr. Shah reports owning stock in Johnson and Johnson unrelated to the present work. Dr. Fisher previously owned stock in Johnson & Johnson unrelated to this work. Dr. Schonberger reports owning stock in Johnson & Johnson unrelated to the present work. Dr. Schonberger reports that his institution has received research support from Merck & Co., Inc., (Rahway, New Jersey) for a study on which he was involved unrelated to the present work.

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