Understanding and Addressing Clinical Variation in Rectal Cancer Care: Application of an Analytic Framework.

Aim: There is substantial, protracted clinical variation in the use of neoadjuvant radiotherapy (with/without chemotherapy) prior to surgical resection for high-risk rectal cancer. In New South Wales (NSW), Australia, in 2018, this ranged from 25% to 59% across health districts. This study aimed to describe specialist clinicians' views about: the amount of clinical variation explained by patient factors and preference (warranted clinical variation) reasons for observed clinical variation solutions to address unwarranted clinical variation METHODS: A study-specific questionnaire was mailed to all rectal cancer specialists in NSW. Quantitative responses were summarized using descriptive statistics. Open-ended responses were analyzed thematically. Follow-up semi-structured interviews were conducted with a subset of participants. Proposed reasons were categorized against the Sutherland and Levesque analytic framework to assess if the observed clinical variation is warranted or unwarranted.

Results: A total of 75 of 210 eligible specialists (36%) completed questionnaires. The majority strongly supported the use of neoadjuvant radiotherapy, with no evidence of equipoise. The maximum difference in the proportion of patients receiving neoadjuvant radiotherapy explained by patient factors or preference was estimated at 10%-20%, substantially less than reported. Proposed reasons for observed clinical variation were largely unwarranted and centered on five main themes: Multidisciplinary team (MDT)-related issues (capacity) Imaging-related issues (capacity) Workforce and practice patterns (capacity) Surgeon treatment preferences (agency) Data quality (evidence) CONCLUSIONS: Improving the consistency of MDT processes, uniform access to high-quality imaging, and improving data quality for performance reporting are focus areas with the potential to reduce unwarranted clinical variation in rectal cancer care.