Costs and economic impact of student‐led clinics—A systematic review

Abstract

Purpose

Student‐led clinics generate a range of benefits to multiple stakeholder groups. Students receive important educational opportunities to advance in their training. Patients with limited access to care may access effective care or a higher amount of effective care and so reduce burden on the health care system. The financial viability of student‐led clinics run by universities is uncertain, and establishing this is complicated by the range of stakeholder costs and benefits that may be involved. This systematic review aimed to synthesise evidence related to the costs and benefits of student‐led clinics and report the methods that have been used to measure these costs and benefits.

Method

We conducted a systematic search of MEDLINE All, PsychInfo, CINAHL, A+ Education (Informit), ERIC (ProQuest) and ProQuest Education databases for studies that reported the costs and/or economic benefits of student‐led clinics from inception through August 2023. Studies were screened for eligibility, and data were extracted including study characteristics, student‐led clinic description and economic outcomes. A narrative synthesis was undertaken due to the heterogeneity of studies.

Results

Of 349 potentially eligible studies, 24 were included. Nine studies (38%) used an outcome description‐monetised approach; four used partial economic evaluation (17%); four employed cost description (17%); two used cost approximation (8%); two used cost analyses (8%); and one was a full economic analysis (4%). Studies examined costs or benefits, from the perspective of a range of stakeholders, but few examined both. Only six studies (25%) had established the clinical effectiveness of their service. Student clinics generate costs for universities in supplying supervision, capital and consumables. Benefits are shared by patients, students, universities and the broader health system, however, economic evaluations to date have largely ignored or not monetised/valued these benefits.

Conclusions

Student‐led clinics involve many different stakeholders, each of whom may incur costs and reap benefits. This complicates how we can go about trying to establish the economic efficiency and viability of student‐led clinics. Measurement of both costs and benefits is needed to understand the efficiency of student‐led clinics in comparison to alternatives. Without the full picture, decision‐makers may make decisions that are ill‐informed and lead to a loss of benefit for society.

Short abstract

Student‐led clinics generate benefits to multiple stakeholders including students, patients the health system & universities. This paper explores the need to measure costs & benefits to ascertain value.

1. INTRODUCTION

Student‐led clinics are dedicated settings where pre‐qualified healthcare students are integrally engaged in delivering health services to patients while supervised by qualified clinicians. ¹ Universities often establish these clinics to address a community's healthcare needs and offer clinical and professional placement opportunities for programmes in medicine, nursing and allied health sciences. ¹ Discipline‐specific or multidisciplinary teams of students from various fields, such as dentistry, dietetics, medicine, occupational therapy, pharmacy, physiotherapy, social work and other allied health professions, provide patient services in these clinics with mutual benefits for the student‐learner and the patient. ² , ³

Many student‐led clinics are established to provide free healthcare to those who cannot otherwise access care and are common in the United States where they ‘act as a safety net for the U.S. medical system’ (Page 1), ⁴ providing free primary medical care to underserved populations. They also expose students to people from different backgrounds to their own. Patients may have complex psychosocial needs ⁵ requiring students to develop the skills to respond with empathy, professionalism and altruism. ⁶

An advantage of student‐led clinics is that students gain clinical experiences in a real‐life setting where sourcing placements in existing health services may be restricted. ³ Students experience firsthand the public health and systemic issues that negatively and disproportionately affect health outcomes for marginalised populations. ⁴ Student‐led clinics can also provide experiences in regional or remote areas and with populations that students may otherwise have little exposure to. ⁷ Moreover, they can provide valuable experience in specialised clinical areas, such as nephrology and oncology, where shortages in the workforce exist. ⁸ , ⁹

Various stakeholders are affected by the operation of student‐led clinics, most notably students, operating institutions (typically universities), student supervisors and academic teaching staff, the health system and the public who are receiving health services. From the student perspective, their interest is predominantly in maximising learning outcomes. According to a systematic review by Briggs and Fronek, participation in interprofessional student‐led clinics can be a protective factor against declining interprofessional attitudes among students. ¹⁰ These findings suggest that such clinics are critical in supporting, developing and maintaining positive interprofessional relationships among future healthcare professionals. According to Briggs and Fronek, several crucial competencies were acquired, including clinical/professional reasoning, effective communication, self‐assurance and professionalism. ¹⁰ These competencies are essential for individuals to excel in their respective fields and work towards achieving their learning and vocational goals. There are also potential benefits for people who use student‐led clinics as consumers. Student‐led clinics may be developed to provide health care to people who may not otherwise have access to services or who experience substantial barriers to accessing health care such as those from low socioeconomic backgrounds, those with language barriers or low health literacy. Student‐led medical clinics are prevalent in the United States, where those with little or no health insurance have few options for care ¹¹ and have been shown to reduce presentations at emergency departments ¹² and hospitalisation rates ¹³ for those attending. Moreover, they have been shown to be effective in managing a range of health conditions, ¹ including diabetes ¹⁴ and hypertension. ¹⁵ Delivery of services to these groups also reduces the overall demand on the health care system. The economic viability of student‐led clinics is uncertain. A recent evaluation of a set of student‐led clinics that met the Institute of Healthcare Improvement ‘Triple Aim’ (including three domains of measurement: population health, experience of care and per capita cost ¹⁶ , ¹⁷ ) found that 12 of the 14 included studies did not include any type of economic evaluation. ² University‐run student‐led clinics use resources that could be allocated to other activities that are potentially more productive from the university perspective, though this may not be the case from a societal perspective when benefits to other non‐university stakeholders are also considered.

To the authors' knowledge, this systematic review is the first that seeks to examine the full range of economic benefits and cost of running student‐led clinics. In conducting this systematic review, our research questions were as follows:

1. What are the costs and benefits of student‐led clinics?

2. What are the methods that have been used to measure these costs?

2. METHOD

The methodology utilised in this literature review was guided by the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) 2020. ¹⁸

2.1. Search strategy

We developed a search strategy that included key words and controlled vocabulary (e.g. MeSH), relating to student‐led clinics, cost and economic benefit. We used this strategy to search the following databases from inception through 8 February 2023: MEDLINE All, PsychInfo, CINAHL, A+ Education (Informit), ERIC (ProQuest) and ProQuest Education. Alerts were set on all databases to identify further studies meeting the search criteria, and extra studies were included until 8 August 2023. The search was restricted to publications in English. The final search strategy was determined a priori and is detailed in Appendix S1.

2.2. Study selection

We included all original studies about student‐led clinics that reported on the cost or economic benefit of the clinic or service. We defined a student‐led clinic as ‘a clinic or service in which healthcare is provided by pre‐qualification health professional students and which cannot function without students’. Abstracts presented at conferences, editorials, theses and dissertations, or articles where full text were not available were excluded.

2.3. Method of review

All studies were imported into Covidence (Veritas Health Innovation Ltd), an online systematic review management software. Two authors (DM and LR) independently screened all potentially eligible studies by reviewing the title and abstract. Full text was then reviewed independently and in duplicate (DM, JF and SM), with disagreements resolved by consensus and, if necessary, adjudication by a third author. A supplementary search was then conducted by means of citation checking the studies included after full‐text screening. All extra studies identified were screened in using the same methods as for those identified in the initial search.

2.4. Data extraction

A data extraction template was developed iteratively by DM using excel and pilot tested by all authors prior to data extraction. Authors were paired, and data were extracted by one author and checked by a second author, with any disagreements resolved by consensus and, if necessary, adjudication by the principal investigator (DM). Extracted data included study characteristics (country, study aim, study design, number of participants) and student‐led clinic description (service provided, student profession). The cost of providing the service (inputs to production such as the cost of clinic operation, supervising staff and consumables) ¹⁹ and benefits or value of the service (consequences or outputs from production such as the value or occasions of services provided) were identified. Funding models were not well described in the studies and so were not included. Studies were also categorised according to the type of economic analysis conducted, based on the number of comparators and consideration of the inputs (i.e. costs) and outputs ²⁰ , ²¹ :

1. Cost approximated: inputs or outputs presented in imprecise monetary terms without any supporting methods (e.g. ‘we estimate the cost to be about US$300 per student’). One or more groups.

2. Outcome description‐monetised: inputs not measured. Outputs measured in monetary terms. One or more groups.

3. Cost description—inputs measured in monetary terms. No measure of output. Single group.

4. Cost analysis—inputs measured in monetary terms. No measure of output. More than one group.

5. Partial economic analysis—inputs measured in monetary terms. Outputs measured in monetary or non‐monetary terms. Single group.

6. Full economic analysis—inputs measured in monetary terms. Outputs measured in monetary or non‐monetary terms. More than one group.

2.5. Appraisal of included studies

Critical appraisal for each paper was undertaken using the Joanna Briggs Institute Checklist for Economic Evaluations. ²² Studies were evaluated in respect to their aims as many authors had included some aspect of cost or benefit measurement without this being explicitly stated as one of the study aims. The data extraction and quality appraisal were completed by the same author and reviewed by a second. Conflicts discussed at research team meetings and resolved by majority decision.

2.6. Data synthesis and analysis

We used a systematic approach to identify the literature and critically examined the content of the reports to synthesise their findings. After considering the diverse range of papers and the various perspectives and contextual backgrounds of the clinics (refer to Tables 1 and 2), we decided to switch from a quantitative data analysis approach to conducting a narrative review. The analysis focussed on describing the nature of economic measurement, including costs (monetary) and outputs (economic outcomes and/or student/patient or university outcomes).

TABLE 1.

Participants, clinic activities and study characteristics.

	N	%
Study design
Non‐randomised, two or more groups	1	4
Cross sectional	19	79
Compared pre‐ and post‐intervention	4	17
Trial‐based or modelling‐based economic evaluation
Compared to standard service delivery	22	92
Modelling	2	8
Type of economic analysis
Cost approximated	2	8
Outcome described‐monetised	9	38
Cost description	4	17
Cost analysis	2	8
Partial economic analysis	4	17
Full economic analysis	1	4
Year of publication
Prior to 2010	0
2010–2015	8	33
2016–2020	8	33
Post 2021	8	33
Study location
USA	19	79
Australia	4	17
South Africa	1	4
Service provided
General medical	6	25
Medication management	5	21
Community dentistry	4	17
Chronic disease management	2	8
Dermatology	2	8
Physiotherapy outpatients	1	4
Podiatry management	1	4
Sleep apnoea management	1	4
Healthy cooking classes	1	4
Various student clinics part of service	1	4
Profession/specialty
Medical students	12	50
Dentistry	4	17
Pharmacy	3	13
Dermatology	2	8
Physiotherapy	1	4
Podiatry	1	4
Multidisciplinary	3	13

TABLE 2.

Descriptions of economic costs (inputs) and benefits (outputs).

Author	Brief description of services	Intended purpose of establishing the clinic	Stated economic aim	Cost (input)	Benefit (consequence/output)
				Hierarchy: personnel, facilities, equipment, consumables, other inputs, student inputs	Number of students educated, number of patients who receive treatment (occasions of service), QALY or other health improvements, health service savings, learning outcomes for students, subsequent employment outcomes
Alhallak et al. 23	Medical clinic delivered by students	‘To help alleviate the cost barrier for … uninsured patients’.	‘To ascertain if student run free clinic save Emergency Department costs and visits’.		Health system savings from reduced service utilisation
Arenas et al. 24	Chronic disease management by medical students	‘To provide physical examinations and preventative healthcare to patients, regardless of insurance status’.	‘To estimate the health and economic impact of a student run clinic compared to the costs using an estimate of cost saved per QALY’.	Cost of student clinic operation (not specified)	Value of QALYs gained
Bailit and McGowan 25	Dental clinic delivered by students	‘To increase the time senior dental students, spend in community clinics providing care to low‐income patients’	‘To assess the impact of community‐based education on dental school's revenue by comparing those with limited versus extensive community education programs’.	Personnel Non‐personnel (not specified)	Student clinic revenue for services provided
Chow et al. 26	Medical students review prescriptions prescribed in free medical clinic	‘To provide free medical care and prescription medication to uninsured adults’	‘To estimate the cost savings associated with the Prescription Assistance Programs (PAP)’.		Patient savings on health care costs
Dvoracek et al. 27	Pharmacy students review prescriptions prescribed in free medical clinic	‘These clinics provide chronic health services to uninsured and underinsured populations, including a closed medication formulary’.	‘To (1) evaluate the impact of implementing cost‐control measures on drug use and financial performance of a student‐led safety net clinic and (2) assess the effect of cost‐control measures on patient care’.		Number of patients provided with services Number of prescriptions dispensed Patient intermediate outcomes Student clinic savings on service costs
Haines et al. 28	Interprofessional outpatient's clinic delivered by medical, nursing and allied health students	‘To provide interprofessional clinical education opportunities to students’	‘To evaluate cost effectiveness of interprofessional student clinic’	Personnel Facilities	Health system savings from reduced service utilisation
Hayes and Hutchison 29	Pharmacy students assist patients at a free medical clinic to make medication choices	To provide computer and internet access to patients and educate them about effectively compare prescription drug benefit plans.	‘To track potential cost savings if patients use recommendations from the plan finder tool’.		Number of patients provided services Patient satisfaction Patient savings from reduced health care costs
He et al. 30	Medical students review prescriptions prescribed in free medical clinic	To provide equitable access to high quality healthcare to a neighbourhood with high rates of unemployment, poverty and chronic disease and low rates of insurance.	To analyse the financial impact of patient drug assistance programs on their clinic.	Cost of membership of medication subsidisation programme	Number of subsidised prescriptions Student clinic savings on service costs
Henry et al. 31	Management of sleep apnoea by medical students	‘To address sleep medicine needs via a primary care‐sleep medicine partnership, including screening, diagnosing, and treating patients with obstructive sleep apnea’.	‘To present a cost‐effective model for the management of sleep apnoea’	Cost of student clinic operation (not specified)	Number of patients provided services
Hua et al. 32	Student run multidisciplinary clinic—evaluation of podiatry service	‘To provide culturally sensitive podiatric care to an uninsured and underserved Hispanic population’.	‘To analyse economic impacts of a student run podiatry clinic & extrapolate the economic impact to a national level’.		Number of occasions of service Value of services provided
Johnston et al. 33	Interprofessional student delivered primary care clinic	‘To provide basic first aid to homeless people attending a soup kitchen’. It was later expanded to provide acute primary healthcare and dispense medication.	‘To determine the costs of establishing and operating a student‐led clinic for an indigent population’.	Personnel Facilities Equipment Consumables Other inputs (overhead/maintenance, pharmacy licence)	Number of prescriptions reviewed Number of medications dispensed
LaGrandeur et al. 34	Sports physical examinations and vaccinations delivered by medial students.	‘Aims to medical students how socioeconomic and cultural factors impact health and access to health care’.	‘… by measuring the value of services and patient satisfaction, we were able to determine the quality of care that a student‐led clinic can provide to its community and the value it has on the patients using the service’		Number of services provided Patient satisfaction Value of services provided
Lalloo and Massey 35	Rural dental clinic staffed by students	‘To provide students with dental students with rural clinical experiences’.	‘To analyse the costs of providing students with a rural clinical experience within the program, the value of treatments provided, and income generated’.	Personnel Equipment Consumables Other inputs (IT, travel)	Value of services provided
Lee et al. 36	Medical students review prescriptions prescribed in free medical clinic	‘To enrol and maintain patients without health insurance in pharmaceutical patient assistance programs to expand patients' access to medication’.	No economic aim stated		Potential patient savings on health care costs Potential student clinic savings on service costs
Lin et al. 37	Free dermatological procedures delivered by medical students	To provide free health services to uninsured patients, including a dermatology.	‘To determine value of dermatological procedures performed at a free clinic’		Number of services provided Patient satisfaction Value of services provided
March et al. 38	Oral health services provision by a student‐led primary care clinic to an Australian rural indigenous community	To provide rural outplacements to students to increase the likelihood of future rural workplace participation by dental graduates, thus expanding oral health services to underserved communities.	‘1. Measure costs and imputed value services provided at student led clinic; 2. Estimate ongoing annual operating costs incurred by university’	Personnel Consumables Other inputs (accommodation, other not specified)	Number of occasions of services Number of services provided by non‐student clinic service Patient wait times Value of services provided
McKenzie et al. 39	Outpatient clinic delivered by medical students	‘Provides free healthcare services to patients … at risk populations unable to afford healthcare. … In addition, serve as a powerful tool to teach students the importance of public health and community service’	‘… is to analyze the strengths and weaknesses of student clinics by gauging the relative economic and medical impact the clinics provide to their patient populations’.	Consumables (medication, laboratory tests) Other costs (not specified)	Patient satisfaction
Mirza et al. 40	Dermatology clinic delivered by medical students	‘To provide sustainable care for the uninsured’.	‘To estimate the value of the services provided using Current Procedural Terminology Medicare codes’.	Cost of student clinic operation (not specified)	Number of occasions of service
Parihar et al. 41	Community clinic delivered by medical, social work, physiotherapy and pharmacy students	‘To act as a safety‐net system for those who lack access to formalize healthcare system’.	‘To estimate the monetary value of clinic visits and laboratory services’.		Number of occasional of service Value of services provided
Smith et al. 42	Community dental clinic delivered by 3rd year students	‘To serve the needs of all population groups with specific emphasis on underserved and underrepresented populations, while remaining financially viable’. ‘To increase the likelihood that its graduates choose a model of dental practice that included a form of service’.	No clear economic aim stated		Number of students educated Student licensure exam outcomes Student career choice Student clinic revenue for services provided
Stauber et al. 43	Community‐based, medical student‐led, culinary class	‘As a means of training for medical students based on the tenants of the Mediterranean diet’.	‘To compare the cost of providing the class to 1000 people and the saving generated through avoiding cardiac infarction’.	Cost of student clinic operation	Patient attitudes and reported behaviour Health system savings from reduced service utilisation
Stickler et al. 44	Student run physical therapy clinic	Not clearly stated	‘To estimate the cost‐of‐service delivery per patient’.	Personnel Facilities Equipment Other inputs (liability insurance) Student time	Number of occasions of service
Stuhlmiller and Tolchard 45	Community development and health checks by nursing students	‘To increase nursing enrolments by increasing capacity for clinical education and to offer student delivered health services to a community with little of no access to health help’.	‘Estimate the healthcare costs avoided by the clinic’.	Personnel Facilities—set up cost	Number of occasions of service Number of people receiving health promotion Health service savings
Thakkar et al. 46	After hours medical care provided by students	‘To increase access to ambulatory care’.	‘To calculate cost savings of avoiding the emergency department (ED) using median ED charge’.	Cost of student clinic operation (not specified)	Health system savings from reduced service utilisation

Abbreviation: QALY, quality adjusted life year.

3. RESULTS

The database search identified 349 potentially eligible studies, of which 21 met criteria for inclusion. A further 26 potentially eligible studies were identified from the supplementary citation checking search, of which three met criteria for inclusion (see PRISMA, Figure 1). A total of 24 studies were included.

FIGURE 1.

Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) 2020 flow diagram for new systematic reviews, which included searches of databases, registers and other sources. [Color figure can be viewed at wileyonlinelibrary.com]

3.1. Participants

Participants, clinic activities and study characteristics are reported in Table 1. Only three countries were represented in the included studies, United States (79%, n = 19), Australia (17%, n = 4) and South Africa (4%, n = 1), and all studies were published since 2010. The most common services provided were general medical (25%, n = 6), medication management (21%, n = 5) and community dental services (17%, n = 4). Student clinic services were mostly provided by medical students (50%, n = 12), dental students (17%, n = 4) and pharmacy students (13%, n = 3), with 13% involving multidisciplinary teams (n = 3).

The time spent by students in the clinics varied by discipline and the clinic's model. Some are run in blocks, with students in dental clinics reported to spend more than 50 days, ²⁵ 3 weeks, ³⁵ 32–36 h per week ⁴² and 8 or 11 weeks. ³⁸ Nursing students spent 80–120 h in a rural clinic in outback New South Wales, Australia. ⁴⁵ Some ran 1 day per week, such as a multidisciplinary clinic in Victoria, Australia, which provided student clinical education for a 3.5‐h session each week for up to nine students per week. ²⁸ Medical students led weekly cooking classes in the Health Meets Food intervention, consisting of six weekly 2‐h cooking classes. ⁴³ Medical clinics and medication clinics run by medical and pharmacy students in the United States were more likely to run after hours, but the hours spent by students were not reported.

3.2. Study methods, measures and characteristics

Twenty‐two studies compared student‐led services to usual cost and two estimated costs avoided. Nineteen studies used cross sectional design (79%), four used a pre‐post intervention or time series (17%), and one used a non‐randomised design with two or more groups (4%). With regards to the type of economic analysis undertaken, nine studies used outcome description‐monetised (38%); four were partial economic evaluations (17%); four were cost descriptions (17%); two were cost approximations (8%); two were cost analyses (8%); and one was a full economic analysis (4%).

3.2.1. Costs (inputs)

Descriptions of the economic costs and benefit reported can be found in Table 2. Twenty‐two of the student‐led health services were provided to patients without charging out‐of‐pocket costs (92%) with the remaining two charging fees (8%) at below market rates. Measures of cost to the student, such as the value of their time, were not reported. When describing their intention for measuring student clinic costs, nine studies intended to capture the full cost to provide the service (38%), four (17%) intended to capture part of the cost to provide, and eleven did not capture the cost to provide the service (46%). Those that attempted to fully cost the service included costings for volunteer time, rent, travel, medical supplies, medications and tests including those that had been donated to the clinic. Four studies reported costs to the government as three received government grants to set up the clinics and one reported funding provide by local government to offset the cost of student placements.

Funding models included four clinics using government medication grants and volunteer supervisors (17%), three used government grants (17%), three used donations and volunteer time (13%), two were funded by the university (8%), one used fee for service and university funding (4%) and one used government Medicare/Medicaide funding. Ten studies did not report their funding model.

3.2.2. Benefits (outputs)

Six studies (25%) had established the clinic effectiveness of their service. Patient benefit was measured and reported in three studies (13%): Stauber et al. compared the participants' knowledge of healthy diets pre and post student‐led education ⁴³ ; pharmacy students changed prescribed medication to reduce costs but maintained patient outcomes ²⁷ ; and patient demonstrated effective student‐provided cancer detection via biopsy results. ³³

One paper measured the benefit to society by calculating changes in quality adjusted life years (QALYs); 11 studies (46%) measured through costs avoided by patients seeking alternative care; one study described but did not monetise costs avoided through the prevention of cardiac arrests (4%); and three studies did not measure the value to society (13%). Six studies (25%) reported benefits to health services through health care costs avoided such as emergency department visits or reduced public health service waiting lists.

None of the studies reported a financial benefit to students. The cost‐effectiveness of student‐led clinics, when compared to traditional placements in health care services, was analysed from the perspective of the university in two studies, ²⁵ , ²⁸ and both found student‐led clinics managed by universities to be less cost‐effective models; however, Haines et al. considered the cost per student day of clinical placement delivered and that this ignored other benefits to society (e.g. delivery of care to people who otherwise may have missed out). Smith et al. found that dental students produced higher income for the university after participating in a student‐led community dental clinic. ⁴² Bailit and McGowan reported financial and strategic benefits to the university such as facilitating larger student cohorts and therefore greater tuition fees, ²⁵ and Smith et al. found that after placement in the student‐led dental clinic, revenue per student increased three‐fold. ⁴²

LaGrandeur et al. reported benefits to the university in medical students learning how socioeconomic and cultural factors impact health and access to healthcare through volunteering at the student‐led clinic. ³⁴ Student‐led clinics may also demonstrate alignment to the mission of the university or school; for example, Smith reported that 32% of graduates practise in community‐based or public health dentistry, which aligned with the aims of the university. ⁴² Stickler reported that student clinics demonstrate social responsibility service learnings and provide opportunity for cultural competency. ⁴⁴ There is a broader range of potential benefits that should be considered in future economic evaluations of student‐led clinics, such as additional learning benefits and workforce benefits including the possible flow on impacts to rural recruitment and retention or recruitment to areas of underserved populations.

3.3. Quality of economic analyses

We evaluated the included studies using the Joanna Briggs Institute Critical Appraisal tool for Economic Evaluations (2017) ⁴⁷ to determine the extent to which each study had addressed the possibility of bias in its design, conduct and analysis (see Table 3). We considered that 20 had a well‐defined research question (76%), 22 provided a comprehensive description of the alternative (86%) but 11 (36%) failed to measure all relevant costs and outcomes for the alternative. Costs and outcomes were assessed to be accurately measured in 16 studies (63%) and were measured credibly in 15 studies (63%). Authors accounted for the impact of time on how costs and outcomes were discounted in two studies (8%). There was an incremental analysis (the additional costs that one service or intervention imposes over another, compared with the additional benefits it delivers) of costs and consequences in seven studies (29%). Sensitivity analyses are used to describe how study results vary with changes in key variables and were conducted in two studies. Study results addressed all issues of concern to users in 20 studies (75%), and the results were deemed generalisable in 50% of studies.

TABLE 3.

Joanna Briggs Institute Critical Appraisal tool for Economic Evaluations scores.

JBI question	Alhallak et al. 23	Arenas et al. 24	Bailit and McGowan 25	Chow et al. 26	Dvoracek et al. 27	Haines et al. 28	Hayes and Hutchison 29	He et al. 30	Henry et al. 31	Hua et al. 32	Johnston et al. 33	LaGrandeur et al. 34	Lalloo and Massey 35	Lee et al. 36	Lin et al. 37	March et al. 38	McKenzie et al. 39	Mirza et al. 40	Parihar et al. 41	Smith et al. 42	Stauber et al. 43	Stickler et al. 44	Stuhlmiller and Tolchard 45	Thakkar et al. 46	% yes
1. Is there a well‐defined question?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	No	Yes	No	Yes	Yes	No	Yes	76%
2. Is there comprehensive description of alternatives?	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	88%
3. Are all important and relevant costs and outcomes for each alternative identified?	Yes	Yes	Yes	Yes	Yes	Yes	No	No	No	Yes	Yes	No	Yes	No	No	Yes	No	No	Yes	No	No	Yes	Yes	No	54%
4. Has clinical effectiveness been established?	No	Yes	No	N/A	Yes	Yes	N/A	N/A	No	No	N/A	Yes	No	No	No	No	No	Yes	No	Yes	Yes	N/A	Yes	N/A	33%
5. Are costs and outcomes measured accurately?	Yes	Yes	Yes	Yes	Unclear	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes	Unclear	Yes	Yes	Yes	Yes	No	No	Yes	No	No	63%
6. Are costs and outcomes valued credibly?	Yes	Yes	No	No	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes	No	No	Yes	No	No	62%
7. Are costs and outcomes adjusted for differential timing?	No	No	No	No	No	Yes	No	No	No	No	Yes	No	No	No	No	No	No	No	No	No	No	No	No	No	8%
8. Is there an incremental analysis of costs and consequences?	No	Yes	No	No	No	No	No	No	No	Yes	Yes	N/A	No	No	N/A	Yes	No	Yes	No	No	Yes	Yes	No	No	29%
9. Were sensitivity analyses conducted to investigate uncertainty in estimates of cost or consequences?	No	Yes	No	No	No	Yes	No	No	No	No	No	No	No	No	No	No	No	No	No	No	No	No	No	No	8%
10. Do study results include all issues of concern to users?	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes	75%
11. Are the results generalizable to the setting of interest in the review?	Yes	Yes	No	Yes	No	Yes	No	Yes	Yes	Yes	No	No	No	Yes	No	Yes	Yes	Yes	No	No	No	Yes	No	No	50%

It should be noted that all student‐led services were evaluated by researchers involved in the development and delivery of those services, increasing the risk of bias.

4. DISCUSSION AND CONCLUSION

This systematic review sought to examine the costs and benefits of student‐led clinics and the methods that have been used to measure these costs. We found that most studies examined either costs or benefits, but not both. Measurement of both costs and benefits is needed to understand the efficiency of student‐led clinics. Costing methodologies varied, with some studies considering only financial costs (i.e. amounts that are paid for) while others also included some non‐financial opportunity costs (i.e. the value of an alternative use being foregone such as volunteer time or donated items). Overall, student‐led clinics appeared to provide benefits to patients, students and the healthcare system when compared to no intervention. However, when the operating cost is considered, student‐led clinics appear to be less cost‐effective than traditional student placements from the university perspective. Cost‐effectiveness from other perspectives were not captured in the included literature.

Like the findings of this study, prior reviews also indicated that a substantial portion of studies only evaluate costs or benefits (but not both), and often in comparison to no intervention. ¹⁹ , ⁴⁸ As such, the lack of clarity in the published literature about features of student‐led clinics that offer good value (i.e. balance of costs and benefits) is unsurprising. In terms of costing methods, Cook et al. examined the continuous professional development literature and stated that only 8 (13%) of 63 studies reported the method to identify costs, 27 (43%) reported the methods to quantity resources consumed and 25 (40%) reported how each resource was assigned a price, with studies reporting a median of 3 costs per study (IQR 2–6). ⁴⁸ In a review of simulation‐based medical education, Zendejas et al. identified a median number of costs per study of 2 (range 1–9), again reflecting the general variability that occurs with measuring cost in health professions education research. ⁴⁹ While we did not explore methods to this level of granularity, our JBI ⁴⁷ scoring for accurate measurement (#5) and credible valuation (#6) of 63% and 62%, respectively, indicates that there is a need for improved rigour in costing for evaluations of student‐led clinics. In terms of data analysis, the consideration of differential timing (i.e. discounting, JBI #7) and the conduct of sensitivity analyses (JBI #9) appear to be uncommon, applied in fewer than 20% of studies in our review and previous reviews. ¹⁹ , ⁵⁰

Careful consideration of which perspectives to include when evaluating student‐led clinics is critical, given the range of stakeholders involved, the range of potential funding mechanisms and that the funders of these clinics are not necessarily the target beneficiaries. To report on perspective in this review, we had to make judgements based on the described methods and results reported—as perspective was rarely explicitly stated. Reporting of perspective is somewhat more common (but still poor) in the continuous professional development literature, reported in 31% of cost studies. ⁵⁰ Challenges with the reporting of perspective is also an issue in the more mature field of health economics, with an analysis of 7605 studies published from 1974 to 2018 finding that 20% of studies did not report study perspective and when perspectives were reported, they were often mis‐specified. ⁵¹

We also found that there were number of benefits arising from student‐led clinic, and failure to consider range of benefits may understate value. Student‐led clinics increase the number or type of student placement opportunities, provide experience in niche specialties or in demographics such low socioeconomic areas or rural and remote communities or they may be developed with the aim of addressing unmet healthcare need. Some are set up to meet a university aim to serve the community and expose students to public health and volunteering. ³⁹ , ⁴² Other stated advantages include an increased likelihood of students working in specialty areas (such as dermatology), ³⁷ rural settings ³⁵ or choosing to work with people from socially disadvantaged group. ³⁴ Smith et al. reported that 32% of graduates were employed in community or public health‐based dental practices, aligning with one of the university's aims in developing the clinic. ⁴² They also noted that by providing earlier clinical experiences through the student‐led clinic, dental students increased in speed and proficiency and were able to bring in 3.5 times more revenue than students who had not worked in the student‐led community dental clinic. ⁴²

Student‐led clinics can also provide low‐cost healthcare to those who may otherwise not be able to access a service. One service described as being offered was to review patients' prescribed medications and use prescription assistance programs to find cheaper alternative medications. ²⁶ Hayes and Hutchinson estimated saving per patient to be reduced by US$ 1157 per patient per year, ²⁹ but Carrol argues that these schemes may be offset by pharmaceutical companies by forcing higher prices on privately paying patients and insurance companies. ⁵² Student‐led clinics provide an opportunity for students to provide service to people from disadvantaged backgrounds and appear to be particularly valuable in a context where there is not an adequate public health system response such as universal health cover. Even in countries where such programmes exist, examples of student‐led clinics who provide service to those that have fallen through the gaps have been identified.

4.1. Limitations

Firstly, our methods were designed to find and include a broad range of manuscripts that evaluated some aspect of the cost and economic benefit of a student‐led clinic, without restriction based on quality. As such, the costs and benefits reported in this review should be interpreted with caution due to the low volume and quality of reporting. Secondly, some included studies had cost as the primary focus whereas others included cost as a secondary outcome; evaluation of the latter of these studies against the JBI checklist may be overly critical. To account for this, we iteratively developed operative definitions with a low threshold for satisfying the JBI items.

4.2. Implications and recommendations

To support the implementation of high‐quality evaluations of student‐led clinics, we developed a series of recommendations to supplement the recommendations in the reference case for continuous professional development activities proposed by Cook et al. ⁵⁰ These recommendations should be read as a supplement to (as opposed to instead of) the existing reference case as we have only added to a subset of the existing recommendations.

1. The primary reason for the establishment of the student‐led clinic should be reported. This should be aligned with the study design and perspectives taken.

2. The perspective should be explicitly stated.

   1. To aid shared understanding, we propose the following descriptors for common cost (input) perspectives:

      1. Student cost: This perspective reflects costs incurred by students as part of participating in the student‐led clinic. It may include fees paid for by students above that of normal course fees, costs incurred related to attending the student‐led clinic that would not otherwise have been incurred (e.g. travel costs, additional accommodation in a rural location) and the value of student time. ¹⁹
      2. Patient cost: This perspective reflects costs incurred by patients to receive the service provided by the student‐led clinic. This may include out‐of‐pocket costs, travel costs and the value of patient time.
      3. Student clinic costs: This perspective reflects the full cost to provide the services offered by the student‐led clinic. It includes facilitator time, administrative staff time, student time, facilities, equipment and consumables. The perspective should not be confused with funding arrangements, wherein it is likely that the university will be paying for most student clinic costs, but there may also be subsidisation from the government.
      4. University cost: This perspective reflects the cost to the university to establish and/or operate the student‐led clinic. It reflects the portion of the student clinic cost that is incurred by the university.
      5. Government cost: This perspective reflects any government subsidisation of student clinic costs as well as payments for eligible services provided by the clinic (e.g. Medicare [Australia], Medicaid [USA]).
   2. We propose the following descriptors for common benefit (output) perspectives:

      1. Patient benefits—patient outcome measures.
      2. Society benefits—increases in QALYs; and/or out‐of‐pocket expenses avoided by patients.
      3. Health system benefits—costs avoided through reduced health service demand such as reduced emergency department presentations.
      4. Student benefits—this perspective include any financial benefits gained by students as part of participating in the student‐led clinic.
      5. University benefits—increased student placement days resulting in larger student cohorts; increased revenue per student.

3. The student‐led clinic model should be described in detail, including the service provided, patient intake processes, the staffing and supervision model, and the broader healthcare context in which the clinic is situated.

4. If seeking to understand the impact of a student‐led clinic on patient health outcomes, the appropriate comparison may not be another form of student clinical education, the appropriate comparison may be a usual care/no intervention. When the student clinic provides a service not otherwise available, the impact of the student clinic on patient health is what is gained by those patients who receive a service, compared to similar patients who are not receiving this service.

These reference case recommendations can be further supplemented through development of consensus reporting guidelines, such as the CHEERS checklist, ⁵³ for the specific context of conducting economic evaluations for student education models, inclusive of student clinics. Future research in this field should consider the impact of different service delivery models such as telehealth, which has had rapid uptake since the COVID‐19 pandemic. Finally, investigations from different research paradigms may assist in greater understanding of the complex phenomena that are student clinics. Realist evaluations ⁵⁴ may be useful for understanding outcomes through their mechanisms and contexts, supported by realist economic evaluations that assist with developing cost‐effectiveness theory of how cost and effectiveness are produced and causally linked.

AUTHOR CONTRIBUTIONS

Debra Mitchell: Conceptualization; writing—original draft; methodology; validation; visualization; writing—review and editing; formal analysis; project administration; data curation. Stephen Maloney: Conceptualization; writing—review and editing; methodology; formal analysis; validation. Luke Robinson: Conceptualization; writing—review and editing; methodology; formal analysis; validation. Terry Haines: Conceptualization; writing—review and editing; supervision. Jonathan Foo: Conceptualization; writing—original draft; writing—review and editing; formal analysis; validation; visualization; methodology.

CONFLICT OF INTEREST STATEMENT

None.

ETHICS STATEMENT

Not applicable.

Supporting information

Appendix S1. Search strategy.

Mitchell D, Maloney S, Robinson L, Haines T, Foo J. Costs and economic impact of student‐led clinics—A systematic review. Med Educ. 2025;59(4):368‐381. doi: 10.1111/medu.15550

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.