Asthma clinical pathways: toward what end?

Abstract

Clinical pathways are increasingly guiding the care of hospitalized patients. A clinical, or critical, pathway is an operational version of a clinical guideline that designates the timing and sequence of desired care.1 Clinical pathways are typically developed for inpatient diagnoses for which care is relatively predictable and depends on multidisciplinary inputs. Clinical pathways may pursue several goals: reduction of unintended variation in care delivery, improved patient education, reduction in resource utilization, and improvement in the quality of care.1 A particular clinical pathway may emphasize some or all of these goals. Only limited evidence supports the efficacy of clinical pathways in achieving these goals despite their growing adoption by hospitals. Because asthma is a major cause of hospitalization in children, clinical pathways have been developed to guide inpatient management. A growing published literature examines these asthma clinical pathways. The focus of these studies indicates that asthma clinical pathways are being developed primarily to reduce costs rather than improve care and outcomes. We believe this represents an important missed opportunity. A pediatric asthma hospitalization is a sentinel health event in a child's life that both flags unmet chronic illness needs and provides a teachable moment to address these needs. Kwan-Gett et al2 evaluated the impact of an asthma clinical pathway in a academic children's hospital. The pathway included the recommendation to “continue or add maintenance anti-inflammatory medication.”2 Yet the only clinical outcomes reported were the use of systemic steroids, which was near universal in the preintervention and postintervention groups, and the provision of peak flow meters.2 Readmission beyond 2 weeks postdischarge or the percentage of children prescribed a controller medication on discharge also were not evaluated. The pathway did not reduce length of stay or cost.2 Johnson et al3 conducted a randomized trial of an …