The Problem of Practice Variation in Newborn Medicine

Neonatal intensive care unit (NICU) teams in the US and around the world receive performance reports that locate their particular value for selected process and outcome measures within the range of values from all reporting NICUs. Understandably, many providers focus primarily, if not exclusively, on their particular value. When a value appears undesirable, providers often justify it in an apparent reflex response rather than critically analysing their data. Exceedingly few reflect on the width or implications of the range within which their performance lies. Standard medical education does not include these skills, yet unwarranted practice variation necessarily compromises a population’s overall quality of care.

Researchers report wide variation in health care resource use with little connection to patient outcomes, challenging the belief that directing incrementally more resources at certain healthcare problems necessarily produces better results. This book provides requisite knowledge to enable readers without research expertise to understand the notion of unwarranted practice variation, how to recognize it, its ubiquity, and why it is generally undesirable – why narrowing is pervasiveness improves quality.

The book begins by describing practice variation, its prevalence, and why it matters.  Next, it examines alternative conceptualizations of NICU work. One view is task-oriented, while the other is aim-oriented. NICU teams rarely articulate their aims explicitly, so this book offers examples that guide thinking and action. Finally, this book asks, “Which rate is 'right'; what is the performance target?” The answer entails identifying the lowest resource use rate associated with desirable outcomes. This requires data describing efficient and predictably performing provision of current evidence-based care, along with relationships to a variety of outcomes. 

Provider conceptualization of healthcare quality also is often vague. The challenge lies in defining this notion operationally. This book does precisely that and gives readers tools to think critically about process, outcome, and quality measures, via some understanding of systems, risk-adjustment modelling, and discriminating signal from noise in process data.

Joseph Schulman, MD, MS, is a neonatologist. He serves as Director of Neonatal Intensive Care Unit (NICU) Quality Measurement and Improvement, and is a Public Health Medical Officer (grade III), at California Children’s Services (CCS) / California Department of Health Care Services (DHCS).  He is responsible for CCS NICU standards of care and reviews clinical care and outcomes at more than 125 NICUs across California, which serve more than 50,000 admissions annually.

Before joining the California DHCS, he was Associate Professor of Clinical Pediatrics (Newborn Medicine) and Associate Professor of Clinical Public Health (Outcomes and Effectiveness) at Weill Medical College of Cornell University, and Attending Neonatologist at New York-Presbyterian Hospital, Weill Cornell Medical Center, in New York City.  He has been a leader in NICU quality improvement efforts in New York, California, as well and nationally/internationally with the Vermont Oxford Network and the Centers for Disease Control (CDC).

His many peer-reviewed publications concentrate on NICU performance evaluation and quality improvement, clinical informatics, and infection prevention/antibiotic use.  He is the sole author of two books published by BMJ Books/Blackwell/John Wiley: 1) Evaluating the Processes of Neonatal Intensive Care, and 2) Managing Your Patients’ Data in the Neonatal and Pediatric Intensive Care Units.  Dr. Schulman’s work straddles knowledge domains uncommonly integrated by a single individual: clinical neonatology, database design and implementation, analytical and enumerative statistical methods, clinical quality improvement, health services research, and claims data analysis.

Dr. Schulman earned his M.D. degree at the University of Pennsylvania and M.S. degree in the Evaluative Clinical Sciences at Dartmouth College, Center for the Evaluative Clinical Sciences, now called the Dartmouth Institute for Health Policy and Clinical Practice.  He completed his neonatal-perinatal medicine fellowship at Duke University Medical Center.