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Low Effectiveness Procedures: Demand & Variation. 06/10/10. Presenters: Andrew Jones, Rob Atenstaedt, Siobhan Jones. Background. Betsi Cadwaladr University Health Board requested support from Public Health Wales to:

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Low effectiveness procedures demand variation
Low Effectiveness Procedures: Demand & Variation


LEPS: Demand & Variation

Presenters: Andrew Jones, Rob Atenstaedt, Siobhan Jones


Betsi Cadwaladr University Health Board requested support from Public Health Wales to:

  • Compile list low effectiveness procedures (LEPs) for Individual Patient Commissioning (IPC) Policy

  • Look at demand and variation for a small number of LEP’s (high volume elective surgical procedures)

LEPS: Demand & Variation


  • ↓ harm, waste, variation

  • Financial

  • Evidence base on LEP’s e.g NICE, Public Health Wales

  • England already robustly performance managing PCT’s on LEP’s

LEPS: Demand & Variation

Better care better value
Better Care Better Value

Better Care Better Value indicators monitor PCT’s on 5 key LEP’s:

  • tonsillectomy,

  • dilatation and curettage,

  • hysterectomy,

  • lower back surgery

  • myringotomy (grommets).

LEPS: Demand & Variation


  • A rapid review of existing guidance from NICE, Public Health Wales and existing UK wide policies performed to identify LEP’s

  • Review of literature on demand and variation was undertaken

  • Detailed analysis of 14 high volume (>20/year) surgical procedures, using PEDW data (undertaken by Public Health Wales Observatory Analysis Team)

LEPS: Demand & Variation

Low effectiveness procedures
Low Effectiveness Procedures

  • Collaboration between BCUHB & Public Health Wales

  • Lists treatments/procedures/ therapies which should not be available or limited availability

  • 70 LEPs identified – included as appendix to the Health Board’s IPC Policy

  • Recommended course of action, with current advice and OPCS code given

  • Procedures split between those should not used in any circumstance and should only be used under strict criteria (subdivided into low & high volume)

  • Cross-checked with neighbouring PCTs/ LHBs

LEPS: Demand & Variation

Analysis of surgical variation results for north wales
Analysis of surgical variation – results for North Wales

  • Analysis suggests significant variation in reported rates of common surgical procedures being undertaken across Wales

  • ↑ statistically significant rates of tonsillectomy, grommet insertion, removal varicose veins, haemorrhoidectomy, apicectomy and D&C/hysteroscopy

  • ↔ Hysterectomy, removal wisdom teeth, removal gallstones

  • ↓ elective caesarean delivery, removal skin lesions, cosmetic orthodontic procedures, removal of ganglia & lumber spine procedures

LEPS: Demand & Variation

Limitations of data analysis
Limitations of data analysis

  • PEDW set up to track hospital activity for payments – not epidemiological analysis

  • Coding – Variation/ Primary procedure codes / Specificity

  • Impossible to tell if procedure clinically appropriate – only illustrates numbers/rates across Wales

LEPS: Demand & Variation

Clinical engagement process
Clinical engagement process

  • Purpose of variation report to support clinical engagement and discussion

  • Limitations of data analysis clearly highlighted

    Presentations on IPC policy/variation report to:

  • HB Board of Directors,

  • LNC, LMC and Medical Staff Committees X3 joint with HB

  • Relevant Clinical Programme Group Board meetings

LEPS: Demand & Variation

Clinical engagement process1
Clinical engagement process

  • Issues with data and coding of procedures highlighted eg haemorrhoidectomy, orthodontics

  • Clinicians given opportunity to identify other procedures from own specialties to include on LEP list e.g. labial reduction

  • LEPs shared with colleagues in other HB’s across Wales e.g. Cardiff & Vale to inform consistent approach

LEPS: Demand & Variation


  • IPC policy appendix produced – ratified as Health Board policy

  • Draft report which included literature review on demand and variation & data analysis produced

  • Revisions to IPC policy and LEP list following feedback from clinicians

LEPS: Demand & Variation


  • HB group now in place to monitor LEPs

  • Urgent review of clinical pathways and waiting lists for LEP’s was conducted

  • Clinical engagement with GP’s re: referral processes

  • Public Health Observatory to turn draft variation paper into all-Wales resource – clinician feedback on coding issues fed in to this process

  • Formal establishment of Wales project to harmonise IPC

LEPS: Demand & Variation

Learning points
Learning points

  • Very powerful tool to start clinical engagement process

  • Clinical engagement takes time….

  • Important Role of LHB Medical Directorate

  • Information professionals should ideally be consulted in advance for advice on coding issues. Balanced in this case against timeliness

  • Efficiency of doing at all Wales level - circulated within professional forums, crossed CEO NHS Wales desk

LEPS: Demand & Variation


  • Jo Charles

  • Claire Jones

  • Sian ap Dewi

  • Hugo Cosh

  • Ciaran Humphreys

  • Rhys Gibbon

  • Martin Duerden (BCU HB)

LEPS: Demand & Variation