Improving quality of care and financial burden in cardiology: a new approach with checklist based clinical pathways - first results

Abstract

Purpose: Clinical pathways (CP) have increasingly been introduced into surgery for standardized elective procedures. The aim of CPs is to enhance effectiveness and quality of care by guideline specific and standardized treatment and to subsequently reduce health care costs. Due to higher disease complexity and less standardized treatment approaches, cardiology and other specialties of internal medicine have so far only seen sporadic introduction of CPs. Methods: In order to study feasibility of CP implementation into the clinical routine of a German university cardiology department, a novel checklist based CP system was broadly introduced. Key elements were 14 disease-specific CPs each detailing relevant diagnostic and therapeutic procedures and mandatory safety checks. Overall goal was to enhance standardization and cross-functional workflow transparency and thereby quality of patient care. Aim of this study was to prove CP-implementation feasibility and to evaluate clinical burden measured in average length of hospital stay (ALOS). Results were measured after 12 months of CP use (> 4500 patients included) and compared to pre CP introduction. Results: Evaluation of used CP documents showed high compliance levels for CP use among staff (CPs used in > 95% of patients) while surveys for all involved functions underlined usability. Following CP introduction no significant change in ALOS was found in (n=380 to 780 per year) e.g., angina pectoris (LOS +2,0%; p=0,78), myocardial infarction (-3,0%; p=0,63) or heart failure (-0,1%; p=0,17), while there was significant LOS-reduction for Afib (-4,9%; p = 0,01). Hypertensive urgency patients showed an increase in LOS (+16,9%; p<0,001) while low-volume (n=29 to 150) revealed substantial LOS reductions (syncope: -23,1%, p<0,001; DVT: -20,8%, p=0,33; PE: -10,2%, p=0,07). Conclusions: We showed feasibility of successful CP introduction within internal medicine by developing a novel checklist based approach built on cross-functional treatment guidance, transparency and regular risk checking. Significant ALOS-reduction for less frequent diseases were shown, further standardization of high-volume diseases seems less promising. LOS increase after CP introduction in hypertensive urgency can most likely be attributed to increased diagnostic screening for secondary hypertension. Since long hospital stays are an increasingly relevant burden for patients, care providers and payers, a broad implementation of the introduced CP approach could be an important lever in lasting quality of care improvements within cardiology.