Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies

Document Type : Review Article


1 Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands

2 Ministry of Health, Welfare, and Sport, The Hague, The Netherlands


A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation.

We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospitalwide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies.

The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection.

Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature.



Commentaries Published on this Paper

  • Linking Costs and Quality in Healthcare: Towards Sustainable Healthcare Systems; Comment on “Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies”

        Abstract | PDF


  • Ways to Improve Hospital Quality - A Health System Perspective; Comment on “Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies”

        Abstract | PDF


  • Complexities of Simultaneously Improving Quality and Lowering Costs in Hospitals; Comment on “Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies”

        Abstract | PDF


Authors' Response to the Commentaries


  • How to Design Integrated Strategies to Improve Healthcare Quality Whilst Containing Healthcare Costs? A Response to the Recent Commentaries

        Abstract | PDF



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Volume 11, Issue 11
November 2022
Pages 2381-2391
  • Receive Date: 24 December 2020
  • Revise Date: 25 December 2020
  • Accept Date: 07 December 2021
  • First Publish Date: 08 December 2021