The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review.

How has the impact of ‘care pathway technologies’ on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

Section Editor: Graeme J. Hankey MD, FRCP Care pathways are structured care plans that are used by the different members of the multidisciplinary team and are usually implemented to manage more than one aspect of patient care (eg, diagnosis, investigation, acute stroke treatment). When used within a case management framework, care pathways can assist health care professionals with clinical decision-making, and they aim to promote organized and efficient patient care that is based on the best-available research evidence and clinical guidelines.1,2 A care pathway can take the form of a printed or electronic document, and it often replaces the patient’s case record for the duration of the hospital stay. Many hospitals have adopted this tool, often as one of the components of a continuous quality improvement scheme, with an aim to improve the quality of stroke care, reduce variation of standards, minimize resource utilization, and educate health care staff.3,4 But is there sufficient evidence to support the use of care pathways for the management of stroke patients? The first Cochrane review of in-hospital care pathways for stroke found some evidence that care pathways may increase the use of certain investigations and reduce the likelihood of urinary tract infections and readmission to hospital.5 However, this benefit …

Care pathways ? the future's bright

Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting. The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews. To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.

A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

This article addresses first the definition of a (care) pathway, and then follows a description of theories since the 1950s. It ends with a discussion of theoretical advantages and disadvantages of care pathways for patients and professionals. The objective of this paper is to provide a theoretical base for empirical studies on care pathways.The knowledge for this chapter is based on several books on pathways, which we found by searching in the digital encyclopedia Wikipedia. Although this is not usual in scientific publications, this method was used because books are not searchable by databases as Pubmed. From 2005, we performed a literature search on Pubmed and other literature databases, and with the keywords integrated care pathway, clinical pathway, critical pathway, theory, research, and evaluation. One of the inspirational sources was the website of the European Pathway Association (EPA) and its journal International Journal of Care Pathways. The authors visited several sites for this paper. These are mentioned as illustration of a concept or theory. Most of them have English websites with more information. The URLs of these websites are not mentioned in this paper as a reference, because the content of them changes fast, sometimes every day.

Clinical pathways are standardized, evidence-based multidisciplinary management plans. Many countries propose their national clinical pathways to improve the quality of care, reduce variation in clinical practice, and increase the efficient use of healthcare resources. Nevertheless, clinical pathways are typically not prescriptive, and the patient's care journey is an individual one, therefore how to handle the variances of clinical pathways is an important issue. Previous methods construct clinical pathway recommendation models either using national standard clinical pathways to obtain the guidance, or using real-world clinical datasets to obtain clinical experience. However, few research tries to use both of them. This will result in existing algorithms that cannot accurately recommend personalized clinical pathway. To overcome the above problems, we propose P ersonalized C linical P athway Rec ommendation(PCPRec). On the one hand, to obtain general clinical pathway recommendations, we built a novel module to pre-train the self-attention model based on the national standard clinical pathway. So that we can use it as a guide to enhance the accuracy of recommending personalized clinical pathway. On the other hand, we obtain the patient's treatment history sequence from real-world clinical datasets, and use the self-attention model for training. The purpose is to learn from the experience of the relationship between clinical items to meet patient's individual needs. Extensive experimental results show that the proposed model achieves the best results compared to state-of-art methods on benchmark datasets.

To the Editor: We read with great interest the article by Saposnik et al regarding the escalating levels of access to in-hospital care and stroke mortality.1 Many authors agree that the management of the patients in stroke care units has been the most substantial advance in stroke care; however, the mechanism by which the stroke care unit management improves outcomes remains uncertain.2 Therefore, in their article Saposnik et al argued that the stroke unit admission does not automatically imply receiving comprehensive care and appropriate interventions, and they analyzed the impact of the organized care in stroke mortality. We suggest that this issue should be further analyzed. We conducted an observational study to this purpose. Retrospective data were collected with standard report forms from the medical records of 253 consecutive patients admitted for ischemic strokes in 29 Italian hospitals in June 2004. Patients with hemorrhagic strokes and …

Care within a stroke unit reduces death or dependency after stroke. However, studies have found significant variations in clinical practice, access to stroke unit care, organisation of patient care, and clinical outcome. Stroke care pathways have been introduced as a method to promote organised and efficient patient care that is based on best evidence and guidelines. We aimed to assess the effects of care pathways, as compared to standard medical care, among patients with acute stroke who had been admitted to hospital. We searched the Cochrane Stroke Group Specialised Trials Register (last searched in May 2001), the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1975-2000), EMBASE (1980-2000), CINAHL (1982-2000), the Index to Scientific and Technical Proceedings (ISTP, May 2001), and HealthSTAR (May 2001). We also handsearched the Journal of Managed Care (1997 to 1998), which was later renamed the Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched. We considered randomised controlled trials and non-randomised studies (quasi-randomised trials, comparative studies, controlled and uncontrolled before and after studies, and interrupted time series) that compared care pathway care with standard medical care. One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data. Data from randomised and non-randomised studies were analysed separately. We found significant statistical heterogeneity in the analysis of two outcomes (computed tomography brain scanning and duration of stay). There were three randomised controlled trials (total of 340 patients) and seven non-randomised studies (total of 1673 patients) that compared care pathway care with standard medical care. We found no difference between care pathway and control groups in terms of death, dependency, or discharge destination. Evidence from mainly non-randomised studies suggests that patients managed using a care pathway may be: a) less likely to suffer a urinary tract infection (OR 0.38, CI 0.18 to 0.79), b) less likely to be readmitted (OR 0.11, CI 0.03 to 0.39), and c) more likely to have a computed tomography brain scan (OR 3.66, CI 1.45 to 9.27) or carotid duplex study (OR 2.45, CI 1.3 to 4.61). Evidence from randomised trials suggests that patient satisfaction and quality of life may be significantly lower in the care pathway group (P=0.02 and P<0.005 respectively). The use of care pathways to manage stroke patients in hospital may be associated with both positive and negative effects on the process of care and clinical outcomes. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify routine implementation of care pathways for acute stroke management or stroke rehabilitation.

IMPROVE-Stroke: IMproving the PRevention Of Vascular Events after Stroke or TIA – a randomised controlled pilot trial of nurse independent prescriber-led care pathway-based risk factor management

To identify and discuss the current state of knowledge about end-of-life care (EOLC) pathways in relation to nursing. Enhancing EOLC has become a central concern in governments' health policies worldwide. End-of-life care pathways have been championed as complex interventions to enhance the quality of end-of-life care. However, concerns have been expressed regarding their purpose, initiation and use. A range of published literature was used to examine EOLC pathways in relation to nursing. Three main themes emerged: nursing's contribution to the evolution of EOLC pathways, implementing EOLC pathways and the influence of EOLC pathways on nursing practice. End-of-life care pathways are to be welcomed as a means by which the quality of EOLC might be enhanced. However, the state of knowledge about EOLC pathways, their development, implementation and influence on families and professional practice is in its infancy. End-of-life care pathways are championed as a means by which the quality of EOLC, for dying people and their families might be enhanced. However, as concerns regarding the quality of EOLC persist, nursing management has a crucial role in driving forward and supporting EOLC pathway development, implementation and evaluation.

The reality of the healthcare marketplace and the medical school curriculum

Objectives To give an overview on the use and prevalence of clinical pathways. Design Cross-sectional descriptive study. Study participants European Pathway Association (E-P-A) contact persons in 23 countries. Results Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care. Conclusions There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.