Impact Of Clinical Pathways Research Articles

Use and impact of clinical pathways across various healthcare settings: A protocol for an umbrella review of global evidence.

The proposed umbrella review aims to assess the use and impact of clinical pathways on professional practice, patient outcomes, length of hospital stay, hospital costs, patient satisfaction, and hospital staff satisfaction through a synthesis of existing systematic reviews and meta-analyses. Following PRIOR guidelines, a systematic search will be conducted in MEDLINE, Epistemonikos, and the Cochrane Library to identify relevant systematic reviews and meta-analyses, from inception till March 2024. Two reviewers will independently screen titles and abstracts, with a third resolving any disagreements. Full-text articles considered potentially relevant will be assessed for eligibility by the same process. The data extraction form will cover information about the review methods, characteristics of the included primary studies, the types of interventions evaluated, and the reported outcomes. This standardized data extraction form will be piloted by the review team on five to ten articles to ensure all relevant information is recorded. The quality of included systematic reviews and meta-analyses will be evaluated using AMSTAR 2. PROSPERO registration number is CRD42024529371. The study will present a narrative synthesis of the findings, addressing the clinical and methodological heterogeneity and assessing the impact of clinical pathways on various healthcare outcomes. This umbrella review will provide evidence-based insights into the effectiveness, challenges, and best practices of clinical pathways, guiding healthcare decision-making and identifying areas for future research. Results will be disseminated widely to inform policy and improve healthcare service delivery. No patient or public contribution, as this paper is a protocol of an umbrella review.

Systemic long-term impact of clinical pathways: UPMC experience with hysterectomy patients

Clinical pathways are defined as evidence-based, multidisciplinary care algorithms that outline essential steps in the management of patients. Pathway implementation in healthcare and industries outside of healthcare demonstrated success in reduction of inefficiencies and elimination of waste of financial and other resources by standardizing processes. The UPMC Health System introduced an evidence-based pathway treatment algorithm for hysterectomy in 2012 with an overarching goal of reducing variations in surgical care and abdominal hysterectomy rates, thereby promoting cost containment and decreased patient morbidity. In 2016, we reported on the impact of hysterectomy pathways on the reduction of open hysterectomy rates and improved patient outcomes between 2012 and 2014. In this follow-up commentary, we looked at years 2015 to 2019 to evaluate the continued success of hysterectomy pathway initiative. Initial studies, as well as follow-up results, both led to the understanding that hysterectomy clinical pathways serve as an effective instrument in decreasing the rates of open hysterectomies, thus reducing complications and undesired practice variability while providing consistent care. We concluded that physician and patient factors that impact the utilization of hysterectomy pathways must be continuously monitored to ensure optimal quality of care for hysterectomy patients. Introduction of clinical pathways across health systems represent an opportunity to introduce a systematic and sustainable change with the goal of achieving improved health outcomes locally and globally.

The Impact of Clinical Pathways on Adoption of Hypofractionated External Beam Radiation in Patients with Low- or Intermediate-Risk Prostate Cancer

Hypofractionated external beam radiation (HF-EBRT) in low- and intermediate-risk prostate cancer provides non-inferior disease control with a more convenient regimen compared to conventionally fractionated external beam radiation (CF-EBRT). Two phase III trials, RTOG 0415 and CHHiP, were published in 2016 confirming the non-inferiority of HF-EBRT to CF-EBRT. However, HF-EBRT remains underutilized nationally. Clinical pathways (CP) are a method for standardizing care in alignment with evidence to avoid unnecessary variations in practice. We evaluated whether a change in our CP would increase utilization of HF-EBRT in patients with low- or intermediate-risk prostate cancer. We implemented a CP for management of patients with low- and intermediate-risk prostate cancer, which was modified in January 2018 to reflect HF-EBRT as the first-choice modality for patients planned for definitive EBRT without brachytherapy. We performed a retrospective analysis on 946 patients seen in consultation at one of 16 network radiation oncology sites between 2015 and 2018. All patients had low-risk (LR), favorable intermediate-risk (FIR), or unfavorable intermediate-risk (UIR) prostate cancer. Patterns of practice in patients with LR, FIR, and UIR prostate cancer were analyzed on a year-by-year basis. In patients treated with EBRT alone, the Chi-square test was used to determine whether utilization of HF-EBRT increased after CP modification. Based on treating physicians’ pathway selection at the time of consultation, from 2015 to 2018, utilization of HF-EBRT increased on a year-by-year basis in LR, FIR, and UIR subgroups (Table 1). Use of CF-EBRT decreased over time in all subgroups from 2015 to 2018 (LR, from 41.1% to 20.0%; FIR, from 55.6% to 35.7%; UIR, from 52.3% to 35.5%). Utilization of brachytherapy alone decreased during the same time period in LR patients (58.9% to 40.0%) but remained relatively stable in FIR (34.3% to 35.7%) and UIR patients (5.3% to 3.2%). Utilization of EBRT with brachytherapy boost remained stable among UIR patients (42.4% to 41.9%). Among patients treated with definitive EBRT alone, utilization of HF-EBRT increased after CP modification from 4.4% to 92.8% (p<0.001). Modification of our CP to reflect HF-EBRT as the first-choice modality for low- or intermediate-risk patients treated with EBRT alone increased the utilization of HF-EBRT from <10% to >90% over a short period of time. Despite the publication of phase III data indicating the non-inferiority of HF-EBRT in 2016, this change in practice pattern was not observed until we modified the CP in January 2018. Clinical pathways are an effective way to standardize practice patterns in alignment with the newest evidence.Abstract 2688; Table 1Risk Category2015201620172018Low Risk0%1.4%5.2%40.0%Favorable-Intermediate Risk0%0%3.7%28.6%Unfavorable-Intermediate Risk0%0%4.7%19.4% Open table in a new tab

The Impact of Clinical Pathways on Antibiotic Prescribing for Acute Otitis Media and Pharyngitis in the Emergency Department.

Although Italian pediatric antimicrobial prescription rates are among the highest in Europe, little action has been taken to improve the appropriateness of antimicrobial prescriptions. The primary aim of this study was to assess changes in antibiotic prescription before and after acute otitis media (AOM) and group A streptococcus (GAS) pharyngitis Clinical Pathway (CP) implementation; secondary aims were to compare treatment failures and to assess change in the total antibiotics costs before and after CP implementation. Pre-post quasi-experimental study comparing the 6-month period before CP implementation (baseline period: October 15, 2014, through April 15, 2015) to the 6 months after intervention (postintervention: October 15, 2015, through April 15, 2016). Two hundred ninety-five pre- and 278 postintervention emergency department visits were associated with AOM. After CP implementation, there was an increase in "wait and see" approach and a decrease in overall prescription of broad-spectrum antibiotics from 53.2% to 32.4% (P < 0.001). One hundred fifty-one pre- and 166 postimplementation clinic visits were associated with GAS pharyngitis, with a decrease in broad-spectrum prescription after CP implementation (46.4% vs. 6.6%; P < 0.001). For both conditions, no difference was found in treatment failure, and total antibiotics cost was significantly reduced after CP implementation, with a decrease especially in broad-spectrum antibiotics costs. A reduction in broad-spectrum antibiotic prescriptions and a reduction in the total cost of antibiotics for AOM and GAS pharyngitis along with an increase in "wait and see" prescribing for AOM indicate effectiveness of CP for antimicrobial stewardship in this setting.

Impact of IT-supported clinical pathways on medical staff satisfaction. A prospective longitudinal cohort study

Introduction Clinical pathways (CPs) have been evaluated with regard to process optimization, economic effects, quality of care, patient satisfaction and staff satisfaction. IT- (information technology) supported CPs, integrated within the HIS (hospital information system), have been implemented in our department in 2004 for the first time world-wide. Herein, we describe the effect of this new concept on medical staff satisfaction. Methods A prospective anonymous and voluntary survey with standardized questionnaires was performed annually from 2006 until 2009 evaluating staff satisfaction concerning CPs. Questions comprised satisfaction with the software, staff's attitude towards CPs and the impact of CPs on work-related processes. Results Within the observation period the term “clinical pathways” became more common among doctors and nurses. Knowledge of the aims of CPs increased significantly in nursing staff (43.4–74.5%), whereas doctor's knowledge was on a constant high level. Standardization, process facilitation and cost effectiveness were the most claimed goals of CPs. Comprehensibility of the single steps within CPs was on a constant high level over the observation period. Generally, graphical layout and usability of CPs ranged on a very high satisfaction level. Acceptability of IT-supported CPs is independent from staffs computer knowledge. Conclusions Staff satisfaction with IT-supported CPs needs to take into account the job characteristics of the different professional groups. IT-supported CPs are leading to a high staff satisfaction, the aims of CPs are widely understood by medical employees. IT-supported CPs may ameliorate staff satisfaction and thereby enhance workflow efficiencies.

What is a clinical pathway? Development of a definition to inform the debate

BackgroundClinical pathways are tools used to guide evidence-based healthcare that have been implemented internationally since the 1980s. However, there is widespread lack of agreement on the impact of clinical pathways on hospital resources and patient outcomes. This can be partially attributed to the confusion for both researchers and healthcare workers regarding what constitutes a clinical pathway. This paper describes efforts made by a team of Cochrane Review authors to develop criteria to assist in the objective identification of clinical pathway studies from the literature.MethodsWe undertook a four-stage process aiming to develop criteria to define a clinical pathway: (1) identify publications exploring the definition of a clinical pathway; (2) derive draft criteria; (3) pilot test the criteria; and (4) modify criteria to maximise agreement between review authors.ResultsPrevious literature and liaison with the European Pathways Association resulted in five criteria being used to define a clinical pathway: (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions'; (4) the intervention had timeframes or criteria-based progression; and (5) the intervention aimed to standardise care for a specific clinical problem, procedure or episode of healthcare in a specific population. After pilot testing it was decided that if an intervention met the first criteria (a structured multidisciplinary plan of care) plus three out of the other four criteria then it was included as a clinical pathway for the purposes of this review. In all, 27 studies were included in the final review. The authors of the included studies referred to these interventions as 'clinical pathways', 'protocols', 'care model', 'care map', 'multidisciplinary care', evidence-based care' and 'guideline'.ConclusionsThe criteria used for the identification of relevant studies for this Cochrane Review can be used as a foundation for the development of a standardised, internationally accepted definition of a clinical pathway.

Cost efficiency and quality assurance as an impact of clinical pathways?

Für etwa zwei Millionen Patienten in Deutschland hat der Schmerz seine Leit- und Warnfunktion verloren und einen selbstständigen Krankheitswert erlangt. Dies macht ein stationäres interdisziplinäres Therapiekonzept erforderlich. Die Komplexität der Leistungserbringung hat direkten Einfluss auf die Kosten der Schmerztherapie. Ziel dieser Studie ist es die Wirkweise eines „Klinischen Behandlungspfades“ hinsichtlich Senkung der Durchschnittskosten bei gleichzeitig gesicherter Versorgungsqualität für die multimodale Schmerztherapie bei Krankheiten und Störungen an Muskel-Skelett-System und Bindegewebe zu untersuchen. Die Studie umfasst 65 Patienten. Anhand einer auf die Anforderung der Prozedur OPS 8-918 ausgelegten Definition können sich Pfadbestandteile ableiten lassen und eine Standardisierung erarbeitet werden. Komplexe Struktur- und Prozessanalysen der multimodalen Schmerztherapie, unter Berücksichtigung von Qualitätsindikatoren, Kosten, Alter und der Begleiterkrankungen der beiden Gruppen werden erforderlich. Die Personal- und Sachkosten der medizinischen und nicht-medizinischen Infrastruktur, die Kosten für Arzneimittel und die Aufenthaltsdauer konnten signifikant verringert werden, während Aspekte der Qualitätssicherung beibehalten beziehungsweise verbessert wurden. Für das geschäftsführende Management eines Krankenhauses ist ein Behandlungspfad ein strategisches Managementinstrument, das der Kostenkontrolle und Kostenoptimierung dienen kann. Ebenso schafft er Transparenz über die Leistungserbringung, reduziert Schnittstellenprobleme und leistet einen Beitrag zur Versorgungsqualität.

The experience of conducting a Cochrane systematic review of the impact of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs

Despite the high prevalence of clinical pathways (CPWs), the results from published studies are inconsistent and contradictory. The plethora of study designs, settings and lack of an agreed definition of a CPW make the relevance of individual studies difficult to apply to clinical settings. It was timely to catalogue and analyse the existing evidence base for CPWs via a rigorous systematic review. Systematic reviews and meta-analyses provide a high level of evidence for the effectiveness of interventions and are commonly employed reviewing strategies for addressing scientific questions in health-related research. This method is especially useful when research results are known to be inconsistent. Instead of conducting another primary evaluation, a detailed review is needed that reflects a summation of available research. This paper reports and discusses methodological and technical issues of a systematic review of the effectiveness of CPWs in hospitals, based on our experience with the Cochrane Effective Practice and Organisation of Care Group.

Effects of clinical pathways in the joint replacement: a meta-analysis

BackgroundA meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs.MethodsMedline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2.ResultsTwenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home.ConclusionThe results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.

Clinical pathways for monitoring and advancing congenital heart disease care

Clinical pathways are multidisciplinary plans that outline the sequence and timing of actions necessary to achieve expected patient outcomes with optimal efficiency. The impact of clinical pathways is greatly influenced by the pathway development and implementation process. Steps in the pathway development process are reviewed. Studies suggest that clinical pathway methodology has been effective in reducing hospital length of stay and healthcare costs while maintaining quality of care in patients with heart disease. However, the potential of clinical pathways for advancing congenital heart disease care has not yet been realized. Future clinical pathways should incorporate evidenced-based guidelines, promote monitoring and evaluation of current practice and outcomes beyond length of hospitalization and healthcare costs, and stimulate research to establish best practice and advance the care of children with congenital heart disease.

First experiences with clinical pathways in carotid surgery

The introduction of guidelines for carotid surgery into praxis. Early experiences with the clinical pathway. With the use of DRG's for reimbursements, a new organization of clinical pathways may play an increasingly important role in the delivery of health care. The impact of clinical pathways as a management tool in the treatment of patients with carotid occlusive disease was studied. Representatives of all involved disciplines identified in which sequence, where, when, by whom and which care a patient with carotid disease should receive. The individual steps of care were analysed, estimating their utility and determining a new plan for a patient's care. The clinical pathway specifies a target time window, defining exactly the internal and external logistics. The early experiences demonstrate that clinical pathways can be a useful tool for improving the quality of health care by improving cost and process transparency. Hospital length of stay was reduced by 2.3 days.

Development and implementation of a clinical pathway programme in an acute care general hospital in Singapore.

A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other health care professionals for a particular diagnosis or procedure. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, pharmacists, physiotherapists and other allied health care professionals with the aim of improving the quality of patient care, while minimizing cost to the patient. The use of clinical pathways has increased over the past decade in the USA, the UK, Australia, and many other developed countries. However, its use in the developing nations and Asia has been sporadic. To the author's knowledge, there is to date, no published literature on the use and impact of clinical pathways on the quality and cost of patient care in the Asian health care setting. This paper provides a qualitative account of the development and implementation of a clinical pathway programme (using the example of patients with uncomplicated acute myocardial infarction) in an acute care general hospital in Singapore. The paper concludes that clinical pathways, when implemented in the context of an acute care hospital, can result in improvements in the care delivery process.

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Impact of clinical pathways for total hip replacement: a community-based analysis.

The implementation of clinical pathways for total hip replacement was carried out by five hospitals in the metropolitan area of Syracuse, New York. This process occurred under the leadership of clinical nurse specialists and nurse managers. It was supported by preadmission patient education programs and active physician involvement. The participating hospitals shared utilization quality assurance data and benchmarked with respect to the experience of Sacramento, California, and each others' progress. The effort produced substantial reductions in hospital stays without adverse impacts on quality of care.

Impact of Clinical Pathways and Practice Guidelines on the Management of Acute Exacerbations of Bronchial Asthma

In 1990, it was estimated that approximately 1% of all US health-care costs (approximately $6.2 billion) were spent on asthma-related health expenses. Of this, hospitalization charges alone exceeded $2.6 billion. Practice guidelines and clinical pathways are being developed to standardize the management of acute asthma with the aim of improving care and safely reducing health-care costs. In this report, we evaluate the impact of an asthma pathway developed and instituted at a large community-based teaching hospital. This pathway was evidence based and was developed by a multidisciplinary group. The study was conducted during a 6-month period in 1995, while a similar period in 1994 was used as a historical control period. Data collected included patient demographics, hospital admission and discharge peak expiratory flow rates, pulse oximetry measurements, length of stay, conversion from hand-held nebulizer to metered-dose inhaler, use of corticosteroids within 24 h of hospitalization, and conversion of i.v. steroids to oral steroids. A total of 42 patients were enrolled during the study period. Of these, 19 were placed on the pathway, while 23 were not treated according to the pathway. There were 38 patients in the 1994 historical control period. For 1995, there was no significant difference between the pathway and nonpathway groups with regard to the length of stay (4.4+/-3.3 vs 3.2+/-2.3 days; p > 0.05), hospital discharge peak expiratory flow rates (324 vs 286 L/min; p > 0.05), or use of steroids (100% vs 91%; p > 0.05). However, a significant increase in conversion from hand-held nebulizer to metered-dose inhaler was noted in the pathway group (68% vs 34%; p < 0.05). The data from 1994 compared to 1995 pathway were similar in that there was no difference in the length of stay (3.4+/-2.1 vs 4.4+/-3.3 days; p > 0.05) and/or use of steroids (92% vs 100%; p > 0.05), while a significant increase in hand-held nebulizer to metered-dose inhaler conversion was observed for the 1995 pathway group (68% vs 26%; p=0.002). We conclude that although the asthma pathway did not significantly reduce length of stay, it was associated with a significant increase in hand-held nebulizer to metered-dose inhaler conversion, resulting in a substantial cost savings of $288,000/year.