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

Area of Science:

• Oncology
• Surgical Oncology
• Health Services Research

Background:

• Significant clinical variation exists in neoadjuvant radiotherapy use for high-risk rectal cancer.
• Rates varied widely (25%-59%) across New South Wales health districts in 2018.

Purpose of the Study:

• To explore specialist clinicians' views on factors contributing to clinical variation in neoadjuvant radiotherapy for rectal cancer.
• To differentiate between warranted (patient-related) and unwarranted (system-related) clinical variation.
• To identify potential solutions for reducing unwarranted variation.

Main Methods:

• A questionnaire survey was distributed to all rectal cancer specialists in NSW.
• Quantitative data were analyzed descriptively; qualitative data underwent thematic analysis.
• Semi-structured interviews were conducted with a subset of participants.
• Reasons for variation were assessed using the Sutherland and Levesque analytic framework.

Main Results:

• 36% of specialists responded (75/210).
• Strong support for neoadjuvant radiotherapy was evident, with no equipoise.
• Patient factors/preference explained only 10%-20% of variation, significantly less than observed.
• Unwarranted variation stemmed from multidisciplinary team (MDT) capacity, imaging capacity, workforce patterns, surgeon preferences, and data quality.

Conclusions:

• Observed clinical variation in neoadjuvant radiotherapy for rectal cancer is largely unwarranted.
• Key areas for improvement include standardizing MDT processes, ensuring uniform high-quality imaging access, and enhancing data quality for performance monitoring.
• These interventions can reduce unwarranted clinical variation and promote consistent, high-quality rectal cancer care.