Purpose: to inform clinical and policy actions to reduce important variation in clinical practice by assessing the feasibility and value of combined analyses of costs, outcomes, and processes of care for patients presenting with chest pain at alternative hospitals.
Method: a risk adjusted cost-effectiveness (RAC-E) and a process mining analysis were undertaken on the same cohort of patients attending the emergency departments (EDs) of four large public hospitals in South Australia. The RAC-E analysis used linked, administrative hospital data for all patients presenting with chest pain from 2003 onwards. Using a decision analytic framework and regression-based adjustment for differences in baseline risks (of increased costs and poor outcomes), estimates were generated of short- and long-term costs and outcomes (related hospital readmission or death, and life years gained, respectively). Process mining is a relatively new area of research, which combines analyses of the content and sequential order of components of the clinical process (workflow analyses), with analyses of timing between key events (performance analyses). Detailed administrative data extracted from the data systems of the four hospitals represented processes within the ED (e.g. mode of transport to ED, triage category, ED diagnosis, time seen by doctor, time admitted, time discharged to ward or to home) and inpatient care settings (e.g. clinical unit, ward type(s) and length of stay(s), procedures received). Process analyses were also linked to ancillary clinical test results following presentation (e.g. troponin levels) and subsequent outcomes (e.g. readmissions within six months), to inform relevant sub-group process analyses.
Result: Incremental analysis of the RAC-E of the four hospitals identified clear differences between the hospitals, demonstrating important consequences of variation in clinical practice with respect to both costs and outcomes. The analysis of process also identified clear areas of variation in clinical practice, including significant differences in protocolised triaging, admission rates, time to transfer to inpatient care, and admission to a cardiac clinical unit.
Conclusion: The reported analyses of RAC-E and clinical processes can be interpreted in combination to quantify the additional health benefits that could be obtained from reduced variation, whilst informing key target areas for improvement. Presented to stakeholders, we hypothesise these data will provide strong incentives to reduce important variations in clinical practice processes and offer a means to evaluate subsequent performance improvement initiatives.
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