Clinical process variation: effect on quality and cost of care

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.

Cross-sectional study using data collected by HealthMETRICS from 1996 to 2007.

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.

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.

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.