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Positive Deviance in Health Care: Beware of Pseudo-Equifinality

  • David C. Aron
  • Brigid Wilson
  • Chin-Lin Tseng
  • Orysya Soroka
  • Leonard M. Pogach
Chapter

Abstract

Objective Identification of best practices constitutes an important strategy for organizational improvement. We compared different criteria (different measurement thresholds, different comparators, and performance consistency over time) on identification of high-performing facilities, especially positive deviants.

Methods The design was serial cross-sectional, using yearly VHA administrative data (2009–2013). Our primary outcome measure was facility-level rate of HbA1c overtreatment of diabetes in patients at risk for hypoglycemia. Outlier status was assessed by three methods.

Results From 2009 to 2013, the rate of overtreatment overall based on a threshold of 6.5% decreased from 28.6% in 2009 to 22.7% in 2013; the rate of undertreatment increased from 7 to 10.3%. Fourteen facilities were identified in the lowest decile of overtreatment. Undertreatment rates among these facilities were compared to the mean overall undertreatment rate; several facilities identified as positive deviants based on overtreatment rates had exceptionally high rates of undertreatment.

Conclusion Because two facilities may arrive at the same results via very different pathways, it is important to consider that a best practice may actually reflect a separate worst practice.

Notes

Acknowledgements

Funding. The work was supported by grants from the Veterans Health Administration (VHA) Health Services Research & Development Service and its Quality Enhancement Research Initiative (QUERI) to Dr. Aron (SCE 12-181), to Dr. Pogach (RRP-12-492), and to Dr. Tseng (IIR 11-077).

Disclaimer. The opinions expressed are solely those of the authors and do not represent the views of the Department of Veterans Affairs.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • David C. Aron
    • 1
    • 2
  • Brigid Wilson
    • 3
  • Chin-Lin Tseng
    • 4
    • 5
  • Orysya Soroka
    • 6
  • Leonard M. Pogach
    • 4
    • 5
  1. 1.Department of Veterans AffairsLouis Stokes Cleveland VA Medical CenterClevelandUSA
  2. 2.Case Western Reserve University School of MedicineClevelandUSA
  3. 3.Department of Veterans AffairsLouis Stokes Cleveland VA Medical CenterClevelandUSA
  4. 4.Department of Veterans Affairs, New Jersey Healthcare SystemEast OrangeUSA
  5. 5.Department of Biostatistics, School of Public HealthRutgers UniversityPiscatawayUSA
  6. 6.Department of Veterans Affairs, New Jersey Healthcare SystemEast OrangeUSA

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