title: Interinstitutional variation in management decisions for treatment of 4 common types of cancer: A multi-institutional cohort study.
abstract: BACKGROUND
  When clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected.
  
  
  OBJECTIVE
  To systematically assess interinstitutional variation in management decisions for 4 common types of cancer.
  
  
  METHODS
  Multi-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011.
  
  
  METHODS
  18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network.
  
  
  METHODS
  25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma.
  
  
  METHODS
  Interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions.
  
  
  RESULTS
  Interinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%.
  
  
  CONCLUSIONS
  Physician identifiers were unavailable, and results may not generalize outside of major cancer centers.
  
  
  CONCLUSIONS
  The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development.
  
  
  BACKGROUND
  National Cancer Institute and National Comprehensive Cancer Network.
authors: Jane C
authors: JC
authors: Weeks
authors: Hajime
authors: H
authors: Uno
authors: Nathan
authors: N
authors: Taback
authors: Gladys
authors: G
authors: Ting
authors: Angel
authors: A
authors: Cronin
authors: Thomas A
authors: TA
authors: D'Amico
authors: Jonathan W
authors: JW
authors: Friedberg
authors: Deborah
authors: D
authors: Schrag
mesh_terms: D001943:Breast Neoplasms / Q000628:therapy*; D002173:Cancer Care Facilities; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000628:therapy*; D019468:Disease Management; D006801:Humans; D008175:Lung Neoplasms / Q000628:therapy*; D008228:Lymphoma, Non-Hodgkin / Q000628:therapy*