We have evaluated the cost-effectiveness of using cell culture to test for chlamydial infections in 9979 patients at a clinic for sexually transmitted diseases. From results of cultures, we have established prevalence data and, using decision-theory analysis, have calculated costs and probabilities of various outcomes. According to their histories and presenting signs and symptoms, patients were classified as at high or low risk for chlamydial infections. Empiric treatment of all patients attending the clinic was the most cost-effective strategy, followed by empiric treatment of high-risk women and culture-based treatment of low-risk women. Obtaining cultures for men at high and low risk was not cost-effective. If universal treatment is not provided, the most cost-effective strategy appears to be empiric therapy in patients at high risk for chlamydial infections and therapy based on diagnostic test results in women at low risk.

Foresight and planning can reduce stress associated with a JCAHO survey. Important resources for the epidemiologist include the Comprehensive Accreditation Manual for Hospitals, recommendations from previous JCAHO surveys, and educational meetings. Communication with colleagues who have been reviewed recently is an invaluable means of preparing for future surveys. Finally, although JCAHO accreditation is important, it is equally important to realize that the primary purpose of quality improvement programs is to improve the structure, process, and outcome of care.

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Quality assurance is rapidly encroaching on the fields of epidemiology and infection control. If we are to lead this most recent revolution in medical care, we must ensure that our approach is structured, that we reassess our goals and methods regularly and that we achieve the maximal benefit from the resources we consume. According to Colloton, "Unless refined or replaced, the unsophisticated methodologies now emerging on several fronts will be used, with or without our endorsement, to assess the quality of care rendered within all of medical practice."