Process, cost, and clinical quality: the initial oral contraceptive visit.

OBJECTIVES: To demonstrate how the analysis of clinical process, cost, and outcomes can identify healthcare improvements that reduce cost without sacrificing quality, using the example of the initial visit associated with oral contraceptive pill use. STUDY DESIGN: Cross-sectional study using data collected by HealthMETRICS between 1996 and 2009. METHODS: Using data collected from 106 sites in 24 states, the unintended pregnancy (UIP) rate, effectiveness of patient education, and unit visit cost were calculated. Staff type providing education and placement of education were recorded. Two-way analysis of variance models were created and tested for significance to identify differences between groups. RESULTS: Sites using nonclinical staff to provide education outside the exam were associated with lower cost, higher education scores, and a UIP rate no different from that of sites using clinical staff. Sites also providing patient education during the physical examination were associated with higher cost, lower education scores, and a UIP rate no lower than that of sites providing education outside of the exam. CONCLUSIONS: Through analyzing process, cost, and quality, lower-cost processes that did not reduce clinical quality were identified. This methodology is applicable to other clinical services for identifying low-cost processes that do not result in lower clinical quality. By using nonclinical staff educators to provide education outside of the physical examination, sites could save an average of 32% of the total cost of the visit.

Clinical process variation: effect on quality and cost of care.

OBJECTIVE: To identify optimal transferable practice processes for provision of a clinical service by studying the relationships among unit cost, clinical outcome, patient satisfaction, and staff satisfaction observed for a discreet service performed at multiple sites in a well-defined patient population. STUDY DESIGN: Cross-sectional study using data collected by HealthMETRICS from 1996 to 2007. METHODS: Data from 165 US clinics in 29 states, totaling 8835 patients and 1583 clinic staff, were reviewed. Four parameters of the initial visit for oral contraceptives (OCs) were measured: unit visit cost, patient satisfaction, staff satisfaction, and clinical indicators, including patient education effectiveness and occurrence of unintended pregnancies within 6 months of the initial OC visit. Patient population and visit type were narrowly defined to ensure intersite comparability. Data collection tools included surveys, time logs, financial work sheets, and on-site visits to document process. RESULTS: Clinical process variation was widespread. The unit cost of an initial OC visit varied from $42 to $206 (mean: $90, coefficient of variation: 38%). Staff satisfaction varied more than patient satisfaction. Clinical indicators, including unintended pregnancies, varied little. The sites achieving lower unit costs demonstrated no apparent decrease in clinical quality. CONCLUSIONS: Clinical processes used to provide initial visits for OC services varied demonstrably across study sites, generating variation in cost with little impact on clinical quality or patient satisfaction. By adopting appropriate components of the optimal practice process, clinical sites could lower the care cost by more than 20% while maintaining or increasing care quality.