Finding the levers for better quality at lower cost

Dr. Padhraig Ryan outlines some international case studies where superior quality drove down costs and argues that, together with many other examples, these suggest we can achieve both quality and cost control.

An ethical imperative facing our nation is the provision of high quality care at affordable cost. Clinicians in HSE Clinical Care programmes demonstrate commendable leadership in seeking these goals. But the relationship between quality and cost control warrants greater policy attention.

Dr. Padhraic Ryan
Dr. Padhraig Ryan

Doesn’t high quality require financial investment? And in the fallout of economic mismanagement and institutional corruption in Ireland, isn’t our capacity to invest in quality circumscribed? Yes, but quality improvement can often lower aggregate costs per patient. These “win-win” situations are strategically important, as they free up resources to benefit additional patients.

We should avoid misguided seismic changes that neglect the fundamental causes of quality and inefficiency.

This paper outlines international case studies where superior quality drove down costs. Together with many other examples, these suggest we can achieve both quality and cost control.

Table 1: Case Studies

Case Study


Health outcomes

Cost changes

Intermountain maternity care Clinical pathway to prevent inappropriate caesarean sections Greater clinical appropriateness, fewer caesarean sections Saved $50 million per year in Utah
Central line associated bloodstream infections 5-item checklist to prevent infection via central line catheters in intensive care units, e.g. sterilise hands and injection site Infections completely eliminated in some settings. Implemented across the US this could save as many as 20,000 lives per year Total potential cost savings in the US estimated at over $2 Billion per year
Geisinger ProvenCare Forty care processes for coronary artery bypass grafting. Valid reason needed for any deviation Estimated 50% drop in complications, greater clinical appropriateness Estimated 50% drop in costs of complications over 90 days


Although the US offers much evidence against a “multi payer” system, and competition between insurers creates perverse incentives that obstruct quality improvement, some clinicians have attained high quality at low cost. Intermountain Healthcare in Utah is often cited as a paragon of quality. To curb inappropriately high caesarean section rates, clinicians introduced a rigorous clinical pathway and reduced the proportion of caesarean sections which were not strongly clinically indicated from 28 per cent to 2 per cent. Estimated savings amounted to $50 million per year.

Major burdens of suffering and death result from central line associated bloodstream infections (CLABSI), a common form of hospital acquired infection. In the US this may inflict up to $2 billion costs and 20,000 deaths per year. CLABSI can be entirely prevented by following a simple 5-item checklist. Implementation depends on culture as much as technical tools, and patient advocates can play a key role in galvanising change.

To limit avoidable perioperative complications, clinicians in the Geisinger health system identified 40 process steps integral to successful coronary artery bypass grafting (heart bypass surgery). This program, known as ProvenCare, compels clinicians to state a valid reason for omission of any step, and was predicted to reduce the costs of complications by 50 per cent over ninety days.

Ireland’s health system possesses key ingredients for improvement, a well-trained workforce and strong clinical leaders. But the system is not yet organized for optimal quality, and Irish citizens are often failed by poor quality. Mustering these ingredients for a successful assault on poor quality and waste requires high-level leadership and vision.

The surest path to a high-performing system involves learning from international experience, and we should avoid misguided seismic changes that neglect the fundamental causes of quality and inefficiency. The Ruane Report shed valuable light on the need to reform health financing, and we need a comparably thorough analysis of the cost-quality relationship. This can provide a path for achieving our goals of high quality, effective, and equitable healthcare.

Dr. Padhraig Ryan
Health Board Research Scholar Trinity College Dublin and Fulbright Scholar, Harvard Medical School