gms | German Medical Science

Objectives: An unexpected patient return to clinic can place a significant financial burden on the patient and family while stressing the healthcare system. Our SMART aim was to decrease the rate of unexpected patient return visits from 1.8 per 100 patient follow-up visits by 50% using Quality Improvement (QI) methodology.

Method: The rate of unexpected returns to clinic (URTC) was tracked at our tertiary care pediatric hospital from February 1, 2014 to May 31, 2015 using a control chart (weekly P-chart), and interventions were studied from January 1 to May 31, 2015. Pareto charts were utilized to determine the most common causes of URTC visits, and interventions were studied using Plan-Do-Study-Act (PDSA) cycles. The medical charges for all URTC patient visits were collected and patient/families were given a cost survey to determine non-medical costs associated with the clinic visits.

Results: The rate of URTC visits dropped from 1.8 to 0.7 (62% decrease) per 100 follow-up visits during the study period, signified by a change in the centerline on the P-chart (p<0.003). The most common reasons for URTC were cast issues (50.5%), new symptom/complaints (29.5%) and persistent/worse symptoms (15.2%). Cast issues were decreased by transitioning from cast treatment to removable splint treatment for all distal radius buckle fractures and all stable metacarpal and phalangeal fractures. This transition additionally decreased the need for scheduled return clinic visits. Similarly, surgical patients were placed into splints instead of casts except for children under 5 and CRPP patients. Physicians, Physician Assistants and Nurses provided standardized patient education in clinic, with diagnosis-specific pamphlets and/or templated discharge summaries given to all clinic patients. The average URTC resulted in $350 of charges ($47.14 in professional fees, $303.24 in hospital fees, radiology fees and supplies). The average URTC cost $70 for families including ½ day of lost wages and travel expenses, not to mention the value of lost time in school for children.

Conclusion: This standardization of patient care resulted in a substantial decrease in the number of patients returning to clinic, both scheduled and unexpectedly. This improvement resulted in a savings of more than $420 per visit saved, including medical and non-medical costs. This model of care will become more important as medical care is transitioned from fee-for-service to value-based reimbursement and/or Accountable Care Organizations.