Clinical evaluation: outcomes, benchmarking, introspection, and quality improvement.

Transforming the current event-driven reimbursement system into a quality powered marketplace will require clinical evaluation of how care is delivered. The managed care marketplace is evolving in three stages, from an event-driven, cost-avoidance model, to which the concepts of "value" and "quality" are added, with the final addition of a more "public health" focus. Clinical evaluation is a scientific process of outcomes assessment, clinical guidelines, and benchmarking. This process was applied to a hospital-based outpatient wound clinic, leading to a determination that the overall clinic Kaplan-Meier median time to healing could be improved. Two groups of patients were studied, 141 retrospectively from 1993 to 1994 and 57 prospectively in 1995. While there was no significant difference in the percentage healed between the groups, a significant difference in the median times to healing was revealed, which was linked to antibiotic use. Even when antibiotics were used prophylactically, the median times for healing were elevated from those without infections. Introspection led to fewer patients receiving preventive antibiotics. The overall lower median time to healing curve in 1995 can be explained by this change in clinical practice. This quality improvement demonstrates the utility of the clinical evaluation process as the healthcare marketplace evolves.