Care pathways ? the future's bright

BackgroundRare diseases (RDs) are often complex, serious, chronic and multi-systemic conditions, associated with physical, sensory and intellectual disability. Patients require follow-up management from multiple medical specialists and health and social care professionals involving a high level of integrated care, service coordination and specified care pathways.Methods and objectivesThis pilot study aimed to explore the best approach for developing national RD care pathways in the Irish healthcare system in the context of a lack of agreed methodology. Irish clinical specialists and patient/lived experience experts were asked to map existing practice against evidence-based clinical practice guidelines (CPGs) and best practice recommendations from the European Reference Networks (ERNs) to develop optimal care pathways. The study focused on the more prevalent, multisystemic rare conditions that require multidisciplinary care, services, supports and therapeutic interventions.Results29 rare conditions were selected across 18 ERNs, for care pathway development. Multidisciplinary input from multiple specialisms was relevant for all pathways. A high level of engagement was experienced from clinical leads and patient organisations. CPGs were identified for 26 of the conditions. Nurse specialist, Psychology, Medical Social Work and Database Manager roles were deemed essential for all care pathways. Access to the therapeutic Health Service Professionals: Physiotherapy, Occupational Therapy, and Speech and Language Therapy were seen as key requirements for holistic care. Genetic counselling was highlighted as a core discipline in 27 pathways demonstrating the importance of access to Clinical Genetics services for many people with RDs.ConclusionsThis study proposes a methodology for Irish RD care pathway development, in collaboration with patient/service user advocates. Common RD patient needs and health care professional interventions across all pathways were identified. Key RD stakeholders have endorsed this national care pathway initiative. Future research focused on the implementation of such care pathways is a priority.

Background Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient’s journey and aim to have: ‘the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome’. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education. While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their ‘active ingredients’ is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are ‘complex interventions’ and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects. This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: ‘Are ICPs effective?’, our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley’s realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions. Objectives To identify the purposes for which ICPs are effective, for whom and in what contexts; To identify the purposes for which ICPs are not effective, for whom and in what contexts; To produce recommendations on how ICPs should be used in the full range of health care settings. Inclusion Criteria Types of participants The review focused on adults and children that accessed health care settings in which ICPs are used. Types of intervention(s)/phenomena of interest For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA): An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations; Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives; The documentation, monitoring, and evaluation of variances and outcomes; The identification of the appropriate resources. Here multidisciplinary is taken to refer to the involvement of two or more disciplines. Types of outcomes Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed. Types of studies To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported TRUNCATED AT 600 WORDS.

Communicating Value: Use of a Novel Framework in the Assessment of an Enhanced Recovery Initiative.

Doctors and hospitals: healthcare's Rubik's cube.

Byline: J. Trivedi, Abdul. Jilani In search of the best possible options for appropriate, evidence-based and effective management of psychiatric disorders, constant research activity, nationally and internationally, is being undertaken to underpin both biological and social factors relevant to early treatment, cost effectiveness and the best possible prognosis. Though psychiatric services are limited in many parts of the world, especially in developing countries like India, even at places where they are available and among those who could have easier access to avail benefits early from psychiatric services, significant proportion of patients find psychiatric services as the last resort after having consultations from many different types of non-psychiatric care providers, including faith healers. In this, lot of crucial time is lost, which could have relevance to better prognosis, as early recognition and management are of utmost importance in psychiatry. [sup][1] This has increased the importance of not only the availability of mental health services in the community for easier access but also the various social and cultural factors which determine the help seeking behavior and pathway of psychiatric care, which is defined as the sequence of contacts with individuals and organizations, initiated by the distressed person's efforts and those of his significant others to seek appropriate help. [sup][2] Research related to help seeking behavior and attitude toward mental illnesses and services which primarily determine the pathway of care has been carried out mainly in developed nations. There is, however, deficiency of information from the developing countries. [sup][3] Effectiveness and Determinant of Pathway of Care As the basic purpose of the pathway of care is to provide early engagement with psychiatric services to minimize the effective cost of treatment and maximize better prognosis, this could be of great help in mental health services. Increasing emphasis is being placed on the implementation of care pathways in all types of healthcare settings, including psychiatry, in the developed countries. [sup][4],[5] Though currently the effectiveness of pathway of care and impact of care pathways on the delivery of mental healthcare is still rudimentary, in practice this could be of great help and effective for the developing nations where there is an urgent need to cater for psychiatric patients with limited psychiatric services. This needs explorations of many overt and covert factors acting as hindrance in the pathway of care and appropriate solutions. These factors play an important role at various steps. Factors causing delay in the initiation of appropriate treatment at the first instance vary from region to region depending upon the sociocultural profile, education, attitude of family/society toward mental illness, perceptions, myths, beliefs, stigma attached with psychiatric disorder, availability/accessibility of psychiatric services and referral patterns, and previous experience of receiving psychiatric help. These determinants also differ in their strength of impact deciding the pathway of care in different geographic regions of world. For example, in the developed nations, the major concern is of stigma, while in the developing nations it is the problem of age old cultural myths and supernatural explanations of psychiatric disorders. There is also a significant role of care providers in deciding the pathways to psychiatric care, the first care provider being the most important for giving direction to the pathway of care to seek further help. [sup][6] Need of Pathway of Care in Developing Nations It is estimated that one in four families has at least one member currently suffering from a mental or behavioral disorder. This results in substantial burden on family members, compromised quality of life, and the negative impact of stigma and discrimination. [sup][7] Also, approximately half of the estimated 450 million people affected by mental illness globally live in Asia-Pacific regions; [sup][8] but due to multiple factors playing as barriers in the pathway of care, many are left untreated, many are partially treated and only a small fraction gets access to appropriate place of treatment. …

Improving Patient Outcomes by Standardizing Care

Critical path and process-mapping methodology was used in industry, particularly in the field of engineering from as early as the 1950s. In the 1980s, clinicians in the USA began to develop the pathway tool within managed care; they were re-defining the delivery of care and attempting to identify measurable outcomes. They were focusing on the patient rather than the system, but needed to demonstrate efficient processes in order to fulfill the requirements of the insurance industry. In the early 1990s the National Health Service (NHS) in the UK funded a patient-focused initiative to support organizational change. This resulted in the investigation and development of concepts such as pathways. In 1990, a team from the UK visited the USA to investigate the use of these pathways, or ‘Anticipated Recovery Pathways’ as they were then called. As a result of this visit, 12 pilot sites for pathways were set up in Northwest London in 1991–92. The West Midlands Pathway Development work also got underway. By 1994, the Anticipated Recovery Pathway had evolved into the Integrated Care Pathway (ICP) in the UK. ICPs were clinician led and driven, and had patients and locally agreed, best practice at their heart. In response to demand for a coordinated UK ICP users group, the National Pathways User Group (later re-named the National Pathways Association [NPA]) was set up in 1994. A popular and well-supported group, it finally folded in 2002, a casualty of the time required by volunteers to lead the group and administer its running. In 2002, at about the same time that the NPA folded, the National Electronic Library for Health (NeLH) Pathways Database was launched to enable the free sharing of ICPs and ICP projects across the UK. Since 1991, ICPs have been developed and implemented across all health care settings in the UK (acute, community, primary, mental health, private, independent, NHS). ICPs are now used all around the world including Africa, Australia, Belgium, Canada, Denmark, Germany, Hong Kong, Italy, the Netherlands, New Zealand, the UK, and the USA. However, the UK has formalized the systematic development, implementation and use of care pathways by embedding them in national policy, identifying them as the vehicle for implementation, demonstration/monitoring and evaluation of all health and social care policies, strategies, initiatives and agendas at the frontline.

Care of stroke patients varies significantly between hospitals.1,2 Implementation of a stroke care pathway may be a method of promoting organized and efficient patient care that is based on the best-available evidence and clinical guidelines. This, in turn, could reduce variations in stroke care. A care pathway can be defined as a plan of care that is developed and used by a multidisciplinary team, and is applicable to more than 1 aspect of care. It can be a printed document or an electronic program, and it usually forms all or part of the patient’s case record. Care pathways are often used in conjunction with other tools such as case management, and they are intended to assist healthcare professionals in clinical decision-making.3,4 Care pathways are also known by other names such as clinical pathway, critical pathway, critical path method, care paths, and CareMaps. Despite the popularity of care pathways, the evidence to support their use is weak. This systematic review aims to assess the effects of care pathways, as compared with standard medical care, among patients admitted to hospital with acute stroke.5 We searched the Cochrane Stroke Group Specialized Trials Register (last searched in May 2001), the Cochrane …

Existing research suggests that care pathways can improve the quality, organization, and consistency of care. However, little is known about the current scope and implementation of care pathways across the world. In collaboration with the European Pathway Association, we designed and implemented a survey on the use of care pathways. The survey could not be representative of national experience with care pathways, given that they are most often developed locally, but rather aimed to provide insight into differences and commonalities. We collected 163 responses (25% response rate) from 39 countries across the world. The survey uncovered variability in the use of evidence-based guidelines, a continued reliance on giving patients information rather than investing in self-management training, suboptimal involvement of patients in the development of, and training on, care pathways, and reported challenges of evaluating the effectiveness of care pathways against a range of indicators. More work is needed...

Clinical care pathway strenghens interprofessional collaboration and quality of health service: a literature review

The implementation of care pathways in hip arthroplasty programs has been shown to result in a decreased length of stay (LOS), but often multiple elements of a care pathway are implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient's prepathway care. In particular, it is unknown what the role of patient expectations pertaining to anticipated LOS alone is on the LOS after primary THA. (1) Does changing the patient's expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient's LOS after primary THA? (2) Is the resultant LOS associated with the patient's age, gender, or day of the week the surgery was performed? We retrospectively compared the LOS in 100 consecutive patients undergoing THA immediately after the implementation of a 4-day care pathway (4-day Group) with 100 consecutive patients, 3 months later, who were also in the same pathway but were told by their surgeon preoperatively and in the hospital to expect a LOS of 2 days (2-day Group). Aside from reeducation by the surgeon, there was no difference in the surgery or intentional changes to the intraoperative or postoperative management of the two groups. Only the patient and the surgeon were made aware of the accelerated discharge plan. We compared the LOS between the two groups and the number of patients who met their discharge goal. As well, the ability to meet the discharge goal for each group was further determined based on age, gender, and day of the week the surgery was performed. Overall, patients in the 2-day Group had a shorter LOS than those in the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). In the 2-day Group, the LOS was 2 days in 32% compared with 8% in the 4-day Group (odds ratio, 4.0; 95% CI, 1.76-9.11; p < 0.001). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). For all patients > 40 years and < 90 years of age, a greater percentage of patients in the 2-day Group went home by postoperative day 2 than those in the 4-day Group (32% compared with 7%; odds ratio, 4.6; p < 0.001). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; p = 0.547). We found that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in the context of a retrospective study whether other caregivers adjusted the pathway in response to the surgeon's preferences, and we suspect this probably did occur, this still points to an opportunity on the topic of expectations setting that future studies should explore. This study highlights the influence patient education and expectations has on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital. Level III, therapeutic study.

This paper aims to discuss some of the issues for the implementation of care pathways for inpatients suffering from schizophrenia. This paper builds upon a previously published paper describing the development of the care pathway. The use of a care pathway may enable care to be delivered in a more efficient and effective way. Very little is known about the development or implementation of care pathways for mental health conditions. Action research guided the process of implementation and led to 29 in-depth interviews. Participant observation and records of 15 working group meetings rounded the data analysis. The nature of the study site changed dramatically over the course of the research programme with many staff leaving the ward. This led to many problems in implementing the care pathway including poor levels of morale and engagement; how the patients were admitted and managed on the care pathway; poor levels of documentation. The findings are particular to this research environment, although some wider issues could be applicable to other sites such as the nature of representing psychiatric work on the care pathway; the evidence-based practice movement and the role of the user and individualized care.

Critical pathways, also known as critical paths, clinical pathways, or care paths, are management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency.1 As competition in the healthcare industry has increased, managers have embraced critical pathways as a method to reduce variation in care, decrease resource utilization, and potentially improve healthcare quality. Cardiovascular medicine in particular is an area in which critical pathways have been embraced. This is due in part to the high volume and high cost associated with cardiovascular diseases and procedures. In addition, the relatively mature guideline process has also contributed to the growth in use of critical pathways in cardiology. Although anchored in clinical guidelines, the critical pathway is a distinct tool that details processes of care and highlights inefficiencies regardless of whether there is evidence to warrant changes in those processes. Clinical guidelines, on the other hand, are consensus statements that are systematically developed to assist practitioners in making patient management decisions related to specific clinical circumstances.2 Although clinical guidelines can and should be used in pathway development, the majority of processes included in a pathway have not been rigorously tested and are generally not addressed in guidelines. Another term that should also be distinguished from critical pathways is clinical protocols. Protocols are treatment recommendations that are often based on guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease treatment variation. However, protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process. In further contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component. Critical pathway techniques were first developed for use in industry as a tool to …

This paper describes the development and implementation of care pathways in two orthopaedic units in Scotland. Although originally developed as a tool of project management, care pathways have been promoted internationally as a response to concerns for patient safety, variability in care and increasing costs. Generally, care pathways can be seen as an example of clinician led rather than management led reform. However, it does reflect a wider shift towards process and away from hierarchical approaches to management. Within the UK care pathways have been promoted as a response to the modernization initiative of the Labour Government. While the initiative was a success in both units it was more difficult to implement care pathways in a trauma rather than an elective unit. In conclusion, it is questionable whether care pathways are a universal response to the requirement for modernization and service redesign in the NHS.

In this paper, the authors show how the implementation of a care pathway can streamline the care for chronic fatigue syndrome (CFS). The methodology of seven phases is used as a guide to develop, implement and evaluate the CFS care pathway. Some patients have already completed the care pathway. With the help of these case studies, a few strengths and weaknesses of the care process can be formulated. The development and implementation of the care pathway result in a structured process. Patients are diagnosed and treated based on an evidence-based method. The care path also leads to an enhancement of the interdisciplinary cooperation. Nevertheless, the criteria for inclusion and exclusion of patients are taken into account insufficiently. Moreover, family doctors should be involved more often. In the future, it is also important to pay more attention to the role of the family members during the treatment. The entire steering group now needs to engage in a discussion about the test pathway and then subsequently put it to use in daily practice. Additional challenges for the steering group include the objective evaluation and the continuous follow-up of the care pathway.