title: Clinical process variation: effect on quality and cost of care.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: HealthMETRICS Partners, Lexington, MA 02421, USA. cmoore@healthmetricspartners.com
authors.forename: Charles L
authors.initials: CL
authors.lastname: Moore
authors.forename: Michael J
authors.initials: MJ
authors.lastname: McMullen
authors.forename: Samuel W
authors.initials: SW
authors.lastname: Woolford
authors.forename: Barry M
authors.initials: BM
authors.lastname: Berger
mesh_terms: D000293:Adolescent; D003278:Contraceptives, Oral, Hormonal; D003430:Cross-Sectional Studies; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007588:Job Satisfaction; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D010818:Practice Patterns, Physicians' / Q000191:economics*; D011787:Quality of Health Care; D012189:Retrospective Studies; D014481:United States
chemical_list: D003278:Contraceptives, Oral, Hormonal