What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review

Rehabilitation in practice: improving delivery of upper limb rehabilitation for children and young people with acquired brain injuries through the development and implementation of a clinical pathway

PURPOSE

Decision making regarding upper limb assessment and management of children and young people (CYP) with acquired brain injury (ABI) is complex. This project aimed to standardise and improve upper limb provision in one residential rehabilitation unit for CYP with ABI.

METHODS

Plan-do-study-act (PDSA) methodology was used. Available evidence was synthesised and recommendations for assessment and intervention of CYP who present at different functional levels were made. A multi-modal knowledge translation process was used for pathway implementation, with regular review and updates in each PDSA cycle. Audit and staff survey at one year and two years post implementation were conducted.

RESULTS

A clinical pathway consisting of an assessment decision tree, intervention matrix and evidence based summaries was developed. Audit at one year demonstrated 70% of CYP had an appropriate assessment form, which increased to 82% at two years. Staff survey showed increased knowledge and use of the pathway, and decreased perceived training needs between years one and two.

CONCLUSIONS

Use of an upper limb pathway can standardise care in line with best available evidence, and increase staff confidence in this complex rehabilitation area. Several years of development and implementation were required to embed its use in practice.Implications for rehabilitationUpper limb rehabilitation for CYP with ABI is complex, with no "one size fits all" assessment or intervention techniques available.Developing a pathway in which the evidence for assessment and management interventions for CYP of different functional levels, and recommendations for clinical practice can improve the consistency of assessment and intervention, and staff confidence with upper limb management.A multimodal strategy for implementation planned from the outset of pathway development can facilitate the translation of the pathway into routine clinical practice.

The Design and Evaluation of Clinical Pathway for Disease Management to Maximize Public Health Benefit

As an implementation strategy, the actual functional scope of clinical pathway (CPW) can be mastered is the basis for evaluating and improving CPW management, which is very important for bridging the evidence-to-practice gap. Here, we propose and discuss a design and evaluation model for CPWs through some theoretical lenses that may help the designer master the actual functional scope of CPWs and accumulate and refine effective key management steps of a specific disease. We can thus determine the best-optimized design with the largest net benefit that allows definition of the core management steps for a specific disease.

Evaluation of a Clinical Pathway for Thyroid Nodular Disease: Timings and Delays in the Diagnosis and Treatment of Thyroid Cancer

Background: Due to the high prevalence of nodular thyroid disease in the general population and the need to rule out malignant tumours, a clinical pathway for nodular thyroid disease was created at our tertiary-level hospital. Our study aimed to quantify timings and delays in diagnosis and treatment in this clinical pathway, specifically for patients who were diagnosed with thyroid cancer. Methods: A retrospective review was conducted of patients who were newly diagnosed with thyroid cancer and who had been previously evaluated in the clinical pathway for nodular thyroid disease at our institution during 2015–2017. Patient demographics, previous diagnostic studies, cytological results, tumour details and key dates were analysed to identify wait times in diagnosis and treatment. Results: Forty patients with thyroid cancer were included. The diagnostic delay had a median time of 60 days, and the treatment delay was dependent on cytopathological results. The main cause for delay in the diagnostic phase was the timing of the thyroid ultrasound performed by the radiology department. In the treatment phase, patients with a cytological result of Bethesda III, V or VI underwent surgery at the suggested time, while those in the Bethesda II or IV category did not. Conclusions: The major delay found in the diagnostic phase was the timing of the thyroid ultrasound performed by the radiology department. We are not suggesting that this step must be eliminated, though the implementation of routine ultrasonography in a thyroid clinic can help identify patients who need more urgent evaluation for fine needle aspiration cytology. In our hospital, decision for surgery is based mainly on the cytopathological report. Imaging studies and/or molecular testing could be considered to reduce treatment delays.

Clinical Pathway for the Diagnosis and Management of Patients With Relapsing-Remitting Multiple Sclerosis: A First Proposal for the Peruvian Population

Background: Relapsing–remitting multiple sclerosis (RRMS) is a subtype of degenerative inflammatory demyelinating disease of multifactorial origin that affects the central nervous system and leads to multifocal neurological impairment.

Objectives: To develop a clinical pathway (CP) for the management of Peruvian patients with RRMS.

Methods: First, we performed a literature review using Medline, Embase, Cochrane, ProQuest, and Science direct. Then, we structured the information as an ordered and logical series of five topics in a defined timeline: (1) How should MS be diagnosed? (2) How should a relapse be treated? (3) How should a DMT be initiated? (4) How should each DMT be used? and (5) How should the patients be followed?

Results: The personnel involved in the care of patients with RRMS can use a series of flowcharts and diagrams that summarize the topics in paper or electronic format.

Conclusions: We propose the first CP for RRMS in Peru that shows the essential steps for diagnosing, treating, and monitoring RRMS patients based on an evidence-based medicine method and local expert opinions. This CP will allow directing relevant clinical actions to strengthen the multidisciplinary management of RRMS in Peru.

Clinical practice and teaching of pharmaceutical care procedures for obstetric diseases

OBJECTIVES

Our goal was to explore the pharmaceutical service and teaching methods of obstetric clinical pharmacists to establish standardised pharmaceutical care procedures for obstetric diseases.

METHODS

According to the evidence-based medicine method, the "Standard of Pharmaceutical Care" was established to standardise the procedure and content of the pharmaceutical care procedure including preface, purpose, scope of application, responsibilities, procedures, references, and appendix, with seven parts in total. The object of the pharmaceutical care procedure was selected by the harmfulness of the disease and the drugs used. The clinical pharmacists in obstetrics formulated the pharmaceutical care procedure for each disease according to the standard and carried out clinical practice and teaching.A retrospective study was conducted to investigate the impact of the pharmaceutical care procedure before and after its implementation on both clinical practice and training. Obstetric pharmaceutical consultation and adverse reaction were the key indicators for clinical practice.The graduation assessment for students was strictly carried out in accordance with the regulations of the Chinese Hospital Association Pharmaceutical Affairs Professional Committee including communication and consultation capacity interview, case assessment, and training procedure assessment.

RESULTS

We established the standards for the pharmaceutical care procedures for three diseases: pregnancy with diabetes; pregnancy with thyroid disease; and pregnancy with hypertensive disorder. The clinical pharmacist conducted the pharmaceutical care procedure, participated in drug treatment management, and improved the recognition of the role of clinical pharmacists by the obstetric clinicians, often inviting the clinical pharmacists to participate in the consultations. The clinical pharmacists discovered and addressed any adverse reactions in a timely manner through patient drug education, subsequently reducing the underreporting of adverse reactions and improving the patient's medication compliance, which aimed to improve the medical quality of patients in our hospital. Second, the use of the pharmaceutical care procedure as a teaching tool helped to train students to grasp the key points of drug treatment and care of the disease and improve the students' scores in the graduation assessment (P<0.05).

CONCLUSIONS

As a pharmacy service and teaching method that can be promoted and implemented, the pharmaceutical care procedure is beneficial for clinical pharmacists to carry out in-depth pharmaceutical services and can also be used as a teaching tool for clinical pharmacist training.

Progression of the Pathway for Public Health Care during the COVID-19 Outbreak at District Health Office

Public health activities under district health offices (DHOs) play a major role in Malaysia's fight against COVID-19. This article aims to describe and illustrate the public health activity pathway in combating the COVID-19 pandemic, and a team of public health workers who are familiar with DHO work settings was created in April 2020 for that purpose. Review of documents and the Ministry of Health's updates was carried out, followed by a series of discussions with stakeholders. Based on the steps in the outbreak investigation tasks, the flow of activities from January to May 2020 was listed in line with the phases of the country's National Movement Control Order 2020. Results show that the activities can be classified into three different sections-namely, the main action areas, category of cases, and level of care. The main process flow of activities comprised the case management and support activities. Case management flow was split into tasks for patients under investigation and persons under surveillance, while the support services existed throughout the phases. The pathways illustrate that the progression of the pandemic translated directly to changes in the pattern of activities, with additional subgroups of activities in accordance with all imposed guidelines.

Designing Dementia Care Pathways to Transform Non Dementia-Friendly Hospitals: Scoping Review

People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients’ routes and processes considering the increasing demographic changes of people with cognitive impairment.

Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways

Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.

Development of clinical pharmacy programs integrated into patient care pathways using adverse event risks

BACKGROUND

In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the "5P project" (Patient personalized clinical pharmacy program integrated into care pathway).

OBJECTIVE

To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods.

METHOD

Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd^, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway.

RESULTS

The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required.

CONCLUSIONS

The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

[Factors promoting and hindering the use of an evidence-based clinical pathway for the management of overweight or obese children and adolescents]

BACKGROUND/OBJECTIVE

Evidence-based clinical pathways can be a useful tool for guideline implementation. However, there seem to be barriers to the use of clinical pathways. The aim of the present questionnaire survey was to assess the perceived usability of the clinical pathway "Overweight/obesity in children and adolescents at primary care level" and to identify factors promoting and hindering the use of the clinical pathway.

METHODS

In January 2020, an online questionnaire survey was sent out to 3,916 general practitioners and 470 pediatricians in Austria. The data collected were analysed descriptively.

RESULTS

A total of 148 people took part in the questionnaire survey (response rate 3.7 %). The majority of respondents indicated that they, in general, perceive evidence-based clinical pathways as helpful (90 %) and also make use of them (57 %). Few respondents (9 %) felt well-informed about new clinical pathways developed in Austria. Most of the respondents considered the clinical pathway "Overweight/obesity in children and adolescents at primary care level" as a useful support (60 %), as a reference work (72 %) or as a facilitator for justifying their approach to their patients (68 %). However, a large proportion of the respondents stated that the clinical pathway is not easily applicable in everyday practice. The three most frequently cited barriers to using the clinical pathway were lack of time resources, lack of structures and lack of financial incentives. Other display and access options (e. g., individualisation, integration into practice software) were most frequently cited as factors that might promote the use of the pathway.

CONCLUSION

Although the majority of the respondents had positive expectations regarding the use of the clinical pathway "Overweight/obesity in children and adolescents at primary care level", many of them still perceived its usability in everyday clinical practice as difficult. The necessary next steps to improve the use of evidence-based clinical pathways seem to be: an economic and practicable design, easy accessibility of clinical pathways and the creation of framework conditions that facilitate their use in everyday practice.

A patient-oriented research approach to assessing patients' and primary care physicians' opinions on trauma-informed care

OBJECTIVE

To gather patients' and primary care physicians' (PCP) opinions on trauma-informed Care (TIC) and to investigate the acceptability of recommendations developed by patient, family, and physician advisors.

DESIGN

Cross-sectional research survey design and patient engagement.

SETTING

Canada, 2017 to 2019.

PARTICIPANTS

English-speaking adults and licensed PCPs residing in Canada.

MAIN OUTCOME MEASURES

Participants were given a series of questionnaires including a list of physician actions and a list of recommendations consistent with TIC.

RESULTS

Patients and PCPs viewed TIC as important. Both patients and PCPs rated the following recommendations as helpful and likely to positively impact patient care: physician training, online trauma resource centres, information pamphlets, the ability to extend appointment times, and clinical pathways for responding to trauma. PCPs' responses were significantly more positive than patients' responses.

CONCLUSION

TIC is important to patients and PCPs. Patients and PCPs believe changes to physician training, patient engagement, and systemic factors would be helpful and likely to positively impact patient care. Future research needs to be conducted to investigate whether these recommendations improve patient care.

Assessing the needs of caregivers of children and adolescents with fetal alcohol spectrum disorders: Results from a survey among families and professionals in Germany

INTRODUCTION

Caring for individuals with fetal alcohol spectrum disorders (FASD) puts a substantial and often life-long burden on affected families. Caregivers' specific needs and demands are, however, not well understood so far. We thus aimed at systematically collecting data on the needs of individuals caring for children and adolescents with FASD.

MATERIALS AND METHODS

Between May 2019 and November 2020, a quantitative survey among caregivers and professionals from across Germany was performed. Participants completed a questionnaire collecting information on the perceived support caregivers receive from various sources as well as the current fulfilment of caregivers' needs. Specifically, the fulfilment of a variety of specific needs summarised in five categories was rated by the participants on a scale ranging from 1 (very good) to 6 (insufficient).

RESULTS

Both caregivers and professionals rated the overall fulfilment of needs rather poorly (mean: 3.94 and 4.27, respectively). Caregivers indicated needs concerning coordination of support (4.74) and relief services (4.44) to be fulfilled the least while needs in the relief services category also received the lowest average grade among professionals (4.57). The needs that the caregivers regarded as most sufficiently fulfilled were their own knowledge about FASD (mean: 1.95) and their knowledge about the causes of their child's problems (mean: 1.87).

CONCLUSIONS

The results of the present study indicate that FASD caregivers are supported insufficiently, while most of their needs remain unmet. Health care planners and providers thus urgently need to identify and implement measures to better address FASD caregivers' needs and demands.

Analysis of Clinical Pathway for Patients With Cleft Lip and Palate

AIM

To evaluate the implementation of a clinical pathway (CP) and identify clinical factors affecting the CP for cleft lip and palate (CLP) patients.

METHODS

A specific CP for CLP patients was developed at CLP Medical Center of Stomatological Hospital affiliated to Nanjing Medical University in 2008. The authors reviewed the collected data of 1810 consecutive patients using the CP for repairing cleft lip, cleft palatal, and alveolar cleft. The patients were treated between January 2008 and December 2019. The rate of completion and risk factors affecting dropout from the CP were analyzed.

RESULTS

The completion rates of the CP in cleft lip, cleft palate and alveolar cleft patients were 68.3% (n = 345), 82.4% (n = 785) and 76.1% (n = 268), respectively. The overall completion rate was 77.2% (n = 1398). The main reasons for dropping out were pre-operation events (n = 212, 11.7%) and post-operation events (n = 188, 10.4%). Among the factors of dropout of CP, laboratory test abnormalities accounted for the majority of pre- and post-operation events (n = 179, 9.9%). In statistical analysis, the combined abnormities and events associated with operations were significant risk factors affecting the dropout rate from CP.

CONCLUSION

The use of CP for CLP patients was reliable but the completion rate was relatively low because of perioperative events. These results provided some evidence of risk factors which should be considered when modifying the protocol of CP for CLP patients in order to achieve higher completion rate.

Assessment of Fall-Related Emergency Medical Service Calls and Transports after a Community-Level Fall-Prevention Initiative

Background: Getting effective fall prevention into the homes of medically and physically vulnerable individuals is a critical public health challenge. Community paramedicine is emerging globally as a new model of care that allows emergency medical service units to evaluate and treat patients in non-emergency contexts for prevention efforts and chronic care management. The promise of community paramedicine as a delivery system for fall prevention that scales to community-level improvements in outcomes is compelling but untested.Objective: To study the impact of a community paramedic program's optimization of a fall prevention system entailing a clinical pathway and learning health system (called Community-FIT) on community-level fall-related emergency medical service utilization rates.Methods: We used an implementation science framework and quality improvement methods to design and optimize a fall prevention model of care that can be embedded within community paramedic operations. The model was implemented and optimized in an emergency medical service agency servicing a Midwestern city in the United States (∼35,000 residents). Primary outcome measures included relative risk reduction in the number of community-level fall-related 9-1-1 calls and fall-related hospital transports. Interrupted time series analysis was used to evaluate relative risk reduction from a 12-month baseline period (September 2016 - August 2017) to a 12-month post-implementation period (September 2018-August 2019).Results: Community paramedic home visits increased from 25 in 2017, to 236 in 2018, to 517 in 2019, indicating a large increase in the number of households that benefited from the efforts. A relative risk reduction of 0.66 (95% [CI] 0.53, 0.76) in the number of fall calls and 0.63 (95% [CI] 0.46, 0.75) in the number of fall-related calls resulting in transports to the hospital were observed.Conclusions: Community-FIT may offer a powerful mechanism for community paramedics to reduce fall-related 9-1-1 calls and transports to hospitals that can be implemented in emergency medical agencies across the country.

Development of a complex intervention to improve mobility and participation of older people with vertigo, dizziness and balance disorders in primary care: a mixed methods study

BACKGROUND

Vertigo, dizziness and balance disorders (VDB) are common in older people and cause restrictions in mobility and social participation. Due to a multifactorial aetiology, health care is often overutilised, but many patients are also treated insufficiently in primary care. The purpose of this study was to develop a care pathway as a complex intervention to improve mobility and participation in older people with VDB in primary care.

METHODS

The development process followed the UK Medical Research Council guidance using a mixed-methods design with individual and group interviews carried out with patients, physical therapists (PTs), general practitioners (GPs), nurses working in community care and a multi-professional expert panel to create a first draft of a care pathway (CPW) and implementation strategy using the Consolidated Framework of Implementation Research and the Expert recommendations for Implementing Change. Subsequently, small expert group modelling of specific components of the CPW was carried out, with GPs, medical specialists and PTs. The Behaviour Change Wheel was applied to design the intervention´s approach to behaviour change. To derive theoretical assumptions, we adopted Kellogg´s Logic Model to consolidate the hypothesized chain of causes leading to patient-relevant outcomes.

RESULTS

Individual interviews with patients showed that VDB symptoms need to be taken more seriously by GPs. Patients demanded age-specific treatment offers, group sessions or a continuous mentoring by a PT. GPs required a specific guideline for diagnostics and treatment options including psychosocial interventions. Specific assignment to and a standardized approach during physical therapy were desired by PTs. Nurses favoured a multi-professional documentation system. The structured three-day expert workshop resulted in a first draft of CPW and potential implementation strategies. Subsequent modelling resulted in a CPW with components and appropriate training materials for involved health professionals. A specific implementation strategy is now available.

CONCLUSION

A mixed-methods design was suggested to be a suitable approach to develop a complex intervention and its implementation strategy. We will subsequently test the intervention for its acceptability and feasibility in a feasibility study accompanied by a comprehensive process evaluation to inform a subsequent effectiveness trial.

TRIAL REGISTRATION

The research project is registered in "Projektdatenbank Versorgungsforschung Deutschland" (Project-ID: VfD_MobilE-PHY_17_003910; date of registration: 30.11.2017).

Action research improved general prerequisites for evidence-based practice

The present study was part of an action research project that was performed to implement a clinical pathway for patients on mechanical ventilation and simultaneously explore the implementation process in a Swedish intensive care unit. The aim of this questionnaire study was to evaluate whether an action research methodology could affect the general prerequisites for evidence-based practice (EBP). Informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework, the study included registered nurses, assistant nurses and anesthesiologists in the unit at start of the project (n = 50) and at follow-up (n = 44). Data was collected with the Evaluation Before Implementation Questionnaire and the Attitudes towards Guidelines Scale.

The results revealed that the general prerequisites for EBP in the setting improved. Compared to baseline measurements, the staff at follow-up conversed significantly more about the importance of the patients’ experiences, research utilization, context and facilitation, while changes with respect to clinical experiences were not significant. The attitudes towards guidelines were perceived as positive at baseline as well as at follow-up and did not significantly change.

Longer professional experience was associated with a slightly lower probability of perceiving that the importance of research utilization was discussed and reflected upon, while belonging to a profession with longer education was associated with a higher probability of this perception. Compared to registered nurses and assistant nurses, the anesthesiologists perceived, to a greater extent, that the importance of clinical experience was discussed and reflected upon in the setting, while there was no significant association with the length of professional experience and/or specific professions regarding the other components.

In conclusion, using action research to implement a clinical pathway methodology seems to set in motion various mechanisms that improve some but not all prerequisites that, according to the PARIHS framework, are advantageous for EBP.

Improving mobility and participation of older people with vertigo, dizziness and balance disorders in primary care using a care pathway: feasibility study and process evaluation

BACKGROUND

Community-dwelling older people are frequently affected by vertigo, dizziness and balance disorders (VDB). We previously developed a care pathway (CPW) to improve their mobility and participation by offering standardized approaches for general practitioners (GPs) and physical therapists (PTs). We aimed to assess the feasibility of the intervention, its implementation strategy and the study procedures in preparation for the subsequent main trial.

METHODS

This 12-week prospective cohort feasibility study was accompanied by a process evaluation designed according to the UK Medical Research Council's Guidance for developing and evaluating complex interventions. Patients with VDB (≥65 years), GPs and PTs in primary care were included. The intervention consisted of a diagnostic screening checklist for GPs and a guide for PTs. The implementation strategy included specific educational trainings and a telephone helpline. Data for mixed-method process evaluation were collected via standardized questionnaires, field notes and qualitative interviews. Quantitative data were analysed using descriptive statistics, qualitative data using content analysis.

RESULTS

A total of five GP practices (seven single GPs), 10 PT practices and 22 patients were included in the study. The recruitment of GPs and patients was challenging (response rates: GP practices: 28%, PT practices: 39%). Ninety-one percent of the patients and all health professionals completed the study. The health professionals responded well to the educational trainings; the utilization of the telephone helpline was low (one call each from GPs and PTs). Familiarisation with the routine of application of the intervention and positive attitudes were emphasized as facilitators of the implementation of the intervention, whereas a lack of time was mentioned as a barrier. Despite difficulties in the GPs' adherence to the intervention protocol, the GPs, PTs and patients saw benefit in the intervention. The patients' treatment adherence to physical therapy was good. There were minor issues in data collection, but no unintended consequences.

CONCLUSION

Although the process evaluation provided good support for the feasibility of study procedures, the intervention and its implementation strategy, we identified a need for improvement in recruitment of participants, the GP intervention part and the data collection procedures. The findings will inform the main trial to test the interventions effectiveness in a cluster RCT.

TRIAL REGISTRATION

Projektdatenbank Versorgungsforschung Deutschland (German registry Health Services Research) VfD_MobilE-PHY_17_003910, date of registration: 30.11.2017; Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00022918, date of registration: 03.09.2020 (retrospectively registered).

Rare disease care pathways in the EU: from odysseys and labyrinths towards highways

Care pathways (CPW) are used worldwide to structure care processes within the patient-centered care concept. Rare diseases (RD), defined as those affecting less than 5 persons per 10,000 and including up to 10,000 different diseases, present unique challenges to CPW development due to their rarity and a large number of disease entities, chronic and frequently disabling nature, heterogeneous manifestation, multisystem involvement, and complexity in diagnostics and treatment. However, failure to develop RD CPWs eventually leads to long diagnostic odysseys, limited and unequal access to RD treatments, and a huge burden of complex care coordination that lies on the shoulders of patients and their families, imposing many personal, professional and social life difficulties, and diminishing their quality of life. In the development of RD CPW, there is a need to ensure smooth horizontal and vertical care integration, multiple transitions, and long-term care coordination across many geographically distant care providers and to find a fine balance between centralized expertise-based, complex, highly specialized services and possibilities for local care provision, patient empowerment and self-management, and digital healthcare. Established in 2017, European Reference Networks may have a high added value through an increase in accessibility and quality of services, economies of scale, scope and speed in the development of lacking evidence-based, educational and other resources for RD CPW, and speeding up innovation development and translation into RD CPW. However, their full benefits may only be reaped through a pan-European collaboration, universal acceptance of common European values and open-mindedness for sometimes disruptive innovation in the provision of healthcare across all Member States of the European Union.

Restructuring Skin Cancer Care in Ontario: A Provincial Plan

There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.

A structured pathway for developing your complex abdominal hernia service: our York pathway

PURPOSE

Clinical pathways are widely prevalent in health care and may be associated with increased clinical efficacy, improved patient care, streamlining of services, while providing clarity on patient management. Such pathways are well established in several branches of healthcare services but, to the authors' knowledge, not in complex abdominal wall reconstruction (CAWR). A stepwise, structured and comprehensive approach to managing complex abdominal wall hernia (CAWH) patients, which has been successfully implemented in our practice, is presented.

METHODS

A literature search of common databases including Embase® and MEDLINE® for CAWH pathways identified no comprehensive pathway. We therefore undertook a reiterative process to develop the York Abdominal Wall Unit (YAWU) through examination of current evidence and logic to produce a pragmatic redesign of our own pathway. Having introduced our pathway, we then performed a retrospective analysis of the complexity and number of abdominal wall cases performed in our trust over time.

RESULTS

We describe our pathway and demonstrate that the percentage of cases and their complexity, as defined by the VHWG classification, have increased over time in York Abdominal Wall Unit.

CONCLUSION

A structured pathway for complex abdominal wall hernia service is one way to improve patient experience and streamline services. The relevance of pathways for the hernia surgeon is discussed alongside this pathway. This may provide a useful guide to those wishing to establish similar personalised pathways within their own units and allow them to expand their service.

Clinical pathways and patient-related outcomes in hospital-based settings: a systematic review and meta-analysis of randomized controlled trials

Clinical pathways represent a multi-disciplinary approach to translate clinical practice guidelines into practical interventions. The literature from 2010 onward regarding the efficacy of adopting a clinical pathway on patient-related outcomes within the in-hospital setting has not been synthesized yet. For this reason, this systematic review and meta-analysis of randomized controlled trials aimed to critically synthesize the literature from 2010 onward about the efficacy of clinical pathways, compared with standard of care, on patient-related outcomes in different populations and to determine the effects of clinical pathways on patient outcomes. We searched PubMed, Scopus, CINAHL, and reference lists of the included studies. Two independent reviewers screened the 360 identified articles and selected fifteen eligible articles, which were evaluated for content and risk of bias. Eleven studies were finally included. Given the commonalities of the measured outcomes, a meta-analysis including eight studies was performed to evaluate the effect size of the associations between clinical pathways and quality of life (OR=1.472 [0.483–4.486]; p=0.496), and two meta-analyses, including four studies, were performed to evaluate the effect sizes of the associations between clinical pathways with satisfaction (OR=2.226 [0.868–5.708]; p=0.096) and length of stay (OR=0,585 [0.349–0.982]; p=0.042). Reduced length of stay appeared to be associated with clinical pathways, while it remains unclear whether adopting clinical pathways could improve levels of quality of life and satisfaction. More primary research is required to determine in specific populations the efficacy of clinical pathways on patient-related outcomes. (www.actabiomedica.it)

Improving management of fever in neutropenic children with cancer across multiple sites

OBJECTIVE

To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types.

METHODS

Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months.

RESULTS

We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables.

CONCLUSION

Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.

Early path nursing improves neurological function recovery in patients with intracerebral hemorrhage: Protocol for a randomized controlled trial

BACKGROUND

To explore the influence of the early path nursing on life quality and the neurological function recovery in the intracerebral hemorrhage (ICH) patients.

METHODS

The experiment was implemented from January 2018 to October 2020 at the First Affiliated Hospital of Soochow University. The experiment was granted through the Research Ethics Committee of the First Affiliated Hospital of Soochow University (2017033). In this experiment, the criteria for inclusion includes: hemorrhagic stroke diagnosed via the MRI or head CT; over 18 years of age; patients with motor dysfunction; The Glasgow Coma Scale > 12. The patients with these symptoms will be excluded: severe cognitive impairment; ischemic stroke; onset time > 3 days; and severe complications. The scale used for the evaluation the neurological function is the American Stroke Scale. This scale contains a total of eleven items, that is, the movements of upper and lower limb, the consciousness level, gaze, visual field, etc. Other outcomes include patient satisfaction and complications.

RESULTS

Evaluation the neurological function and quality of life will be shown in Table 1.

CONCLUSION

The early path nursing can promote the neurological function recovery in the ICH patients.

TRIAL REGISTRATION NUMBER

researchregistry6327.

Meaningful Text: Total Hip Replacement Patients’ Lived Experience of a Nursing Care Plan Written in Lay Language

Background:

Person-centred care involves respecting patients’ experiences, preferences, and needs, as well as sharing information with them and involving them in care planning. Scant research has been conducted on how it influences patients to have direct access to their care planning when it has been established through the use of standardised care plans or pathways. In the orthopaedic ward in which this study was conducted, a standardised nursing care plan for total hip replacement patients (THR), which was originally written in professional language, was rewritten in lay language and used as peri-operative teaching material for this patient group.

Study Aim:

To explore the meaning THR patients ascribe to the lived experience of reading and retaining their standardised nursing care plan in lay language during their hospital stay.

Methods:

The data collection and analysis followed a method adapted by the Vancouver School of Doing Phenomenology. Data were collected through 12 in-depth interviews with six THR patients.

Results:

The main finding was that the participants acquired knowledge from the text of the care plan that was understandable and meaningful, as evidenced by the empowering impact it had on them. This impact included improved psychological wellbeing, more open communication, and the provision of a tool to keep track of care. Some revisions of the care plan were recommended.

Conclusion:

The study suggests that a patient version of standardised care plans can act as an important educational tool for THR patients that can empower them to manage their health situations.

Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews

Clinical or care pathways are developed by a multidisciplinary team of healthcare practitioners, based on clinical evidence, and standardized processes. The evaluation of their framework/content quality is unclear. The aim of this study was to describe which tools and domains are able to critically evaluate the quality of clinical/care pathways. An overview of systematic reviews was conducted, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using Medline, Embase, Science Citation Index, PsychInfo, CINAHL, and Cochrane Library, from 2015 to 2020, and with snowballing methods. The quality of the reviews was assessed with Assessment the Methodology of Systematic Review (AMSTAR-2) and categorized with The Leuven Clinical Pathway Compass for the definition of the five domains: processes, service, clinical, team, and financial. We found nine reviews. Three achieved a high level of quality with AMSTAR-2. The areas classified according to The Leuven Clinical Pathway Compass were: 9.7% team multidisciplinary involvement, 13.2% clinical (morbidity/mortality), 44.3% process (continuity-clinical integration, transitional), 5.6% financial (length of stay), and 27.0% service (patient-/family-centered care). Overall, none of the 300 instruments retrieved could be considered a gold standard mainly because they did not cover all the critical pathway domains outlined by Leuven and Health Technology Assessment. This overview shows important insights for the definition of a multiprinciple framework of core domains for assessing the quality of pathways. The core domains should consider general critical aspects common to all pathways, but it is necessary to define specific domains for specific diseases, fast pathways, and adapting the tool to the cultural and organizational characteristics of the health system of each country.

Ontological framework for standardizing and digitizing clinical pathways in healthcare information systems

BACKGROUND AND OBJECTIVE

Most healthcare institutions are reorganizing their healthcare delivery systems based on Clinical Pathways (CPs). CPs are novel medical management plans to standardize medical activities, reduce cost, optimize resource usage, and improve the quality of service. However, most CPs are still paper-based and not fully integrated with Health Information Systems (HIS). More CP computerization research is therefore needed to fully benefit from CP's practical potentials. A major contribution of this research is the vision that CP systems deserve to be placed at the centre of HIS, because within CPs lies the very heart of medical planning, treatment and impressions, including healthcare quality and cost factors.

METHODS

An important contribution to the realization of this vision is to fully standardize and digitize CPs so that they become machine-readable and smoothly linkable across various HIS. To achieve this goal, this research proposes a framework for (i) CP knowledge representation and sharing using ontologies, (ii) CP standardization based on SNOMED CT and HL7, and (iii) CP digitization based on a novel coding system to encode CP data. To show the feasibility of the proposed framework we developed a prototype clinical pathway management system (CPMS) based on CPs currently in use at hospitals.

RESULTS

The results show that CPs can be fully standardized and digitized using SNOMED CT terms and codes, and the CPMS can work as an independent system, performing novel CP-related functions, including useful data analytics. CPs can be compared easily for auditing and quality management. Furthermore, the CPMS was smoothly linked to a hospital EMR and CP data were captured in EMR without any loss.

CONCLUSION

The proposed framework is promising and contributes toward solving major challenges related to CP standardization, digitization, and inclusion in today's modern computerized hospitals.

Smartphone-Based Clinical Pathways in Pediatrics: A Case Study

Evidence-based medicine is a major evolution in the way medical practice and reasoning are structured. This approach aims at guiding patient care through rigorous, explicit and judicious evidences. In this contribution, we present the case study of the deployment of a smartphone-based system to manage clinical pathways and its impact during two years in the pediatric department of the university hospital of Rennes, France. We also tackle smartphone acceptability and easiness of use by pediatricians.

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use

BACKGROUND

Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls.

METHODS

We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates.

RESULTS

The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group.

CONCLUSIONS

The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Oral nutrition interventions in patients undergoing gastrointestinal surgery for cancer: A systematic literature review

PURPOSE

Weight loss and poor food intake have been shown to affect several outcomes in patients undergoing surgery for gastrointestinal cancer. This review aims to examine the effect of pre-, post- or perioperative nutrition interventions focused on increasing oral energy or protein intake in patients undergoing surgery for gastrointestinal cancer. Interventions using standard oral nutrition supplements and/or dietary counselling were included. The primary outcome was weight change, and secondary outcomes were energy and protein intake. A secondary aim was to examine this effect in malnourished patients.

METHODS

Embase, Medline, CINAHL and CENTRAL were searched from inception to September 2019 for relevant randomised controlled trials. Study quality was assessed using the revised Cochrane Collaboration risk of bias tool for randomised trials. The quality of evidence for each outcome was assessed using GRADE.

RESULTS

Fourteen articles met the inclusion criteria. Studies assessed patients undergoing surgery for gastric, colorectal, oesophageal and pancreatic cancers. The interventions studied included oral nutrition supplements and/or dietary counselling. Five studies reported preoperative interventions; five studies reported post-operative interventions; six studies reported post-discharge interventions; and two studies reported perioperative interventions. Overall, low or very low quality evidence was found to support the use of oral nutrition supplements to positively influence weight and increase energy and protein intake in the preoperative period and immediate post-operative period. Very low quality evidence was found to support the use of oral nutrition interventions to influence weight, energy or protein intake in the post-discharge period. Very limited evidence with high risk of bias was found to support positive effects of nutrition intervention in malnourished patients.

CONCLUSIONS

This review demonstrates limited evidence for the use of oral nutrition supplements to increase intake and positively influence weight in patients undergoing surgery for gastrointestinal cancer. Overall, results were heterogeneous leading to inconsistent results. Further research into optimal nutrition support interventions and timing of interventions is required.

Clinical pathways on a mobile device

Clinical pathways have been successfully implemented in the primary care setting in New Zealand, Australia and the UK. Despite wide adoption and decreased costs, these pathways have yet to translate evidence into clinical practice while also saving providers time-an important barrier for the translation of evidence at the point of care. The goal of this project was to determine if future development of a point-of-care mobile application should be undertaken with design principles using the theoretical framework of Hick's law. Three new-to-practice providers participated in three plan-do-study-act cycles using these pathways installed on mobile devices to determine if they were a feasible, efficient and useful method to implement evidence. The project was a success with all three participants wishing to continue using the pathways after project completion. Participants felt the digital clinical pathways were the next evolution of the popular UpToDate software platform and helped them apply the latest evidence better than other available tools. While these results are promising, there were also limitations. Participants felt the lack of chart integration coupled with time constraints made full integration challenging and suggested launching the platform using a variety of delivery systems. The project's findings suggest that future application development using the developed design principles would be worth further consideration. If this mobile application ultimately proved successful, the application framework could be implemented on a larger scale, thus improving patient outcomes and saving providers time.

The effect of acute coronary syndrome care pathways on in-hospital patients: A systematic review

BACKGROUND

Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices.

OBJECTIVES

This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes.

METHODS

This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

RESULTS

Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies.

CONCLUSION

Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.

Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department

OBJECTIVE

There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield.

METHODS

A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis.

RESULTS

1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53).

CONCLUSIONS

There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.

Toward uniform and controlled clinical pathways in cancer care: a qualitative description

QUALITY ISSUE

The definition of clinical pathways (CPs) and their application are heterogeneous. Each center is used to choose whether to adopt this instrument or not and to variably conceive its features We consider CPs as the necessary description of the cancer patient journey and we emphasize their role as the user view of clinical processes rather than a local translation of guidelines.

CHOICE OF SOLUTION

We proposed a unique CPs model for all the centers of our regional network, with the aim of making CPs accountable and comparable. We also established a central quality evaluation.

IMPLEMENTATION

Through a multi-step process, the model was proposed to the 22 Regional centers. Landmark characteristics of the project were: the involvement of hospital administrations; reference to a unique set of guidelines; a peer-review and open evaluation.

EVALUATION

Of the 374 expected CPs, 253 (68%) were received and evaluated. A median number of 131 items were the object of evaluation in each hub center and 77 in each spoke center. About 79.5% items were considered well described, 15.5% were absent and 5.0% partially described. The median percentage of fulfilled indicators was 85.6% in hub CPs and 82.2% in spoke CPs. Although, not all diseases were equally covered through the territory a high degree of homogeneity and a good quality of compilation were achieved.

LESSONS LEARNED

The project was shown to be feasible and achieved its goal. We suggest this process as a functional way for building uniform cancer CPs.

Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review

Background

Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered.

The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC).

Methods

A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed.

Results

Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied.

The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators.

Conclusions

In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience.

Trial registration

PROSPERO 2018 CRD42018087689.

Non-Small Cell Lung Cancer from Genomics to Therapeutics: A Framework for Community Practice Integration to Arrive at Personalized Therapy Strategies

Non-small cell lung cancer (NSCLC) is a heterogeneous disease, and therapeutic management has advanced with the identification of various key oncogenic mutations that promote lung cancer tumorigenesis. Subsequent studies have developed targeted therapies against these oncogenes in the hope of personalizing therapy based on the molecular genomics of the tumor. This review presents approved treatments against actionable mutations in NSCLC as well as promising targets and therapies. We also discuss the current status of molecular testing practices in community oncology sites that would help to direct oncologists in lung cancer decision-making. We propose a collaborative framework between community practice and academic sites that can help improve the utilization of personalized strategies in the community, through incorporation of increased testing rates, virtual molecular tumor boards, vendor-based oncology clinical pathways, and an academic-type singular electronic health record system.

A Therapeutic and Diagnostic Multidisciplinary Pathway for Merkel Cell Carcinoma Patients

Merkel Cell Carcinoma (MCC) is a highly aggressive neuroendocrine neoplasm of the skin. Due to its rarity, the management of MCC is not standardized across centers. In this article, we present the experience of the Veneto region in the North-East of Italy, where a committee of skin cancer experts has proposed a clinical pathway for the diagnosis and treatment of MCC. Putting together the evidence available in the international literature, we outlined the best approach to the management of patients affected with this malignancy step- by- step for each possible clinical situation. Crucial in this pathway is the role of the multidisciplinary team to deal with the lack of robust information on each aspect of the management of this disease.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians' Perspectives of Clinical Pathways

Introduction:

Healthcare costs are rising, and clinical pathways (CPW) are one means to promote high-value care by standardizing care and improving outcomes without compromising cost or quality. However, providers do not always follow CPW, and our understanding of their perceptions is limited. Our objective was to examine pediatric hospital medicine (PHM) and pediatric emergency medicine (PEM) physician perspectives of CPW.

Methods:

We conducted semistructured, in-depth, one-on-one qualitative interviews with PHM and PEM physicians between February 2017 and August 2017. Interviews were audio-recorded, professionally transcribed, and accuracy verified. Using an inductive analytic strategy, we systematically coded the data to identify themes.

Results:

We interviewed 15 PHM and 15 PEM physicians. These providers identified many benefits and limitations of CPW, which positively or negatively impact resource utilization, communication, education of personnel, patients, and families, as well as practice behaviors and attitudes. Perceived benefits included (1) reduction of unnecessary utilization, (2) standardization of care, (3) improved communication, (4) education of oneself and others, and (5) confidence and validation when actions align with CPW. Limitations of CPW were (1) resource utilization for revisions, updates, and dissemination; (2) “tunnel vision” and cognitive biases; (3) loss of autonomy; (4) prescriptive medicine; (5) information overload; (6) pressure to adhere; and (7) guilt if actions do not align with CPW.

Conclusions:

CPW are tools with advantages and disadvantages that are used and viewed differently by providers. Such insight into how physicians perceive CPW may help to optimize hospital improvement work and enhance high-value care.

How to Ease the Pain of Taking a Diagnostic Point of Care Test to the Market: A Framework for Evidence Development

Bringing a diagnostic point of care test (POCT) to a healthcare market can be a painful experience as it requires the manufacturer to meet considerable technical, financial, managerial, and regulatory challenges. In this opinion article we propose a framework for developing the evidence needed to support product development, marketing, and adoption. We discuss each step in the evidence development pathway from the invention phase to the implementation of a new POCT in the healthcare system. We highlight the importance of articulating the value propositions and documenting the care pathway. We provide guidance on how to conduct care pathway analysis as little has been published on this. We summarize the clinical, economic and qualitative studies to be considered for developing evidence, and provide useful links to relevant software, on-line applications, websites, and give practical advice. We also provide advice on patient and public involvement and engagement (PPIE), and on product management. Our aim is to help device manufacturers to understand the concepts and terminology used in evaluation of in vitro diagnostics (IVDs) so that they can communicate effectively with evaluation methodologists, statisticians, and health economists. Manufacturers of medical tests and devices can use the proposed framework to plan their evidence development strategy in alignment with device development, applications for regulatory approval, and publication.

Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators

BACKGROUND

Hymenoptera venom allergy (HVA) is an underestimated condition representing an important cause of morbidity and mortality worldwide. Preventing future allergic reactions in patients who have already developed a systemic reaction is based on the correct management of the acute phase of the reaction followed by a correct diagnosis and, where indicated, prescription of adrenaline autoinjectors and VIT. A possible strategy to optimize care processes and to improve outcomes is the implementation of a Diagnostic and Therapeutic Care Pathways, also known as Integrated Care Pathways or Clinical Pathways (CPWs). The aim of the care pathway is to enhance the quality of care by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To our knowledge, currently in Italy as well as in Europe, there is no CPWs codified for the management of HVA patients. This paper describes the development of the clinical content of a care pathway for the management of HVA.

METHODS

The methodology applied is based on the eight step method to build the clinical content of an evidence-based care pathway suggested by Lodewijckx et al.

RESULTS

Three hundred and seventeen different clinical activities were extracted from the selected literature. The expert panel was involved in their evaluation, expressing a judgment of relevance through the Delphi study. As a result, 126 clinical activities were appraised to be valid and feasible. The final recommendations (126) were translated into 123 key interventions. Six indicators were produced by the clinical activities.

CONCLUSION

A set of 123 key interventions and of six process indicators were found to be appropriate for the development and standardization of the clinical content of the Hymenoptera venom allergy care pathway.

Variance Risk Identification and Treatment of Clinical Pathway by Integrated Bayesian Network and Association Rules Mining

With the continuous development of data mining techniques in the medical field, variance analysis in clinical pathways based on data mining approaches have attracted increasing attention from scholars and decision makers. However, studies on variance analysis and treatment of specific kinds of disease are still relatively scarce. In order to reduce the hazard of postpartum hemorrhage after cesarean section, we conducted a detailed analysis on the relevant risk factors and treatment mechanisms, adopting the integrated Bayesian network and association rule mining approaches. By proposing a Bayesian network model based on regression analysis, we calculated the probability of risk factors determining the key factors that result in postpartum hemorrhage after cesarean section. In addition, we mined a few association rules regarding the treatment of postpartum hemorrhage on the basis of different clinical features. We divided the risk factors into primary and secondary risk factors by realizing the classification of different causes of postpartum hemorrhage after cesarean section and sorted the posterior probability to obtain the key factors in the primary and secondary risk factors: uterine atony and prolonged labor. The rules of clinical features associated with the management of postpartum hemorrhage during cesarean section were obtained. Finally, related strategies were proposed for improving medical service quality and enhancing the rescue efficiency of clinical pathways in China.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

Clinical pathways for primary care: current use, interest and perceived usability

Objective

Translating clinical evidence to daily practice remains a challenge and may improve with clinical pathways. We assessed interest in and usability of clinical pathways by primary care professionals.

Methods

An online survey was created. Interest in pathways for patient care and learning was assessed at start and finish. Participants completed baseline questions then pathway-associated question sets related to management of 2 chronic diseases. Perceived pathway usability was assessed using the system usability scale. Accuracy and confidence of answers was compared for baseline and pathway-assisted questions.

Results

Of 115 participants, 17.4% had used clinical pathways, the lowest of decision support tool types surveyed. Accuracy and confidence in answers significantly improved for all pathways. Interest in using pathways daily or weekly was above 75% for the respondents.

Conclusion

There is low utilization of, but high interest in, clinical pathways by primary care clinicians. Pathways improve accuracy and confidence in answering written clinical questions.

Variation in the initial assessment and investigation for ovarian cancer in symptomatic women: a systematic review of international guidelines

Background

Women with ovarian cancer can present with a variety of symptoms and signs, and an increasing range of tests are available for their investigation. A number of international guidelines provide advice for the initial assessment of possible ovarian cancer in symptomatic women. We systematically identified and reviewed the consistency and quality of these documents.

Methods

MEDLINE, Embase, guideline-specific databases and professional organisation websites were searched in March 2018 for relevant clinical guidelines, consensus statements and clinical pathways, produced by professional or governmental bodies. Two reviewers independently extracted data and appraised documents using the Appraisal for Guidelines and Research Evaluation 2 (AGREEII) tool.

Results

Eighteen documents from 11 countries in six languages met selection criteria. Methodological quality varied with two guidance documents achieving an AGREEII score ≥ 50% in all six domains and 10 documents scoring ≥50% for “Rigour of development” (range: 7–96%). All guidance documents provided advice on possible symptoms of ovarian cancer, although the number of symptoms included in documents ranged from four to 14 with only one symptom (bloating/abdominal distension/increased abdominal size) appearing in all documents. Fourteen documents provided advice on physical examinations but varied in both the examinations they recommended and the physical signs they included. Fifteen documents provided recommendations on initial investigations. Transabdominal/transvaginal ultrasound and the serum biomarker CA125 were the most widely advocated initial tests. Five distinct testing strategies were identified based on the number of tests and the order of testing advocated: ‘single test’, ‘dual testing’, ‘sequential testing’, ‘multiple testing options’ and ‘no testing’.

Conclusions

Recommendations on the initial assessment and investigation for ovarian cancer in symptomatic women vary considerably between international guidance documents. This variation could contribute to differences in the way symptomatic women are assessed and investigated between countries. Greater research is needed to evaluate the assessment and testing approaches advocated by different guidelines and their impact on ovarian cancer detection.

How “care values” as discursive practices effect the ethics of a care-setting

Purpose

This paper examines how certain care values permeate, legitimize and authorize hospitalized-older-adults’ care, technologies and practices. The purpose of this paper is to expose how values are not benign but operate discursively establishing “orders of worth” with significant effect on the ethics of the care-setting.

Design/methodology/approach

The paper draws from a discursive ethnography to see “up close” on a surgical unit how values influence nurse/older-adult-patient care occasions in the domain of older-adults and functional decline. Data are from participant observations, conversations, interviews, chart reviews and reviewed literature. Foucauldian discursive analytics rendered values recognizable and analyzable as discursive practices. Discourse is a social practice of knowledge production constituting and giving meaning to what it represents.

Findings

Analysis reveals how care values inhere discourses like measurement, efficiency, economics, risk and functional decline (loss of capacity for independent living) pervading care technologies and practices, subjugating older adults’ bodies to techniques, turning older persons into measurable objects of knowledge. These values determine social conditions of worth, objectifying, calculating, normalizing and homogenizing what it means to be old, ill and in hospital.

Originality/value

Seven older adult patients and attendant nurses were followed for their entire hospitalization. The ethnography renders visible how care values as discursive practices rationalize the social order and operations of everyday care. Analytic outcomes offer insights of how dominant care values enabled care technologies and practices to govern hospitalized-older-adults as a population to be ordered, managed and controlled, eliding possibilities of engaging humanistic patient-centered care.

A Strategy for the Renovation of a Clinical Pathways Program

Supplemental Digital Content is available in the text.

Introduction:

Clinical pathways (CPs) translate best available evidence to the local care context and intend to inform clinical decision-making, optimize care, and decrease variation. This article describes a CPs program improvement process at a free-standing academic children’s hospital. Aims: (1) improve the pathway development process; (2) identify and address gaps; (3) strengthen measurement; (4) increase efficiency in cycle time to build a pathway; (5) increase multidisciplinary participation; (6) integrate into the electronic health record ; and (7) and increase pathway utilization.

Methods:

We renovated the CP program using a structured, improvement process. A series of internal stakeholder and external colleague interviews informed the process. To improve the program, we developed and implemented different interventions.

Results:

The streamlined process reduced the overall time for completion from a median of 15 to 5 months (measured from the date of first meeting with the clinical improvement team to approval), a 70% increase in efficiency. Between 1994 and 2015, the hospital had 33 CPs. There was a 78% increase in the total number of pathways after the renovation with 26 additional pathways.

Conclusions:

Renovation of the CP program led to early success through an improved development process, alleviation of programmatic gaps, inclusion of measures within each pathway, increased timely completion, multidisciplinary involvement, integration into the electronic health record, and improved utilization. Initial results are encouraging, and the lessons learned should be helpful to other programs. Further program development is ongoing, focusing on continued improvements in implementation and overall program measures.

Analysis of a thyroid nodule care pathway: Opportunity to improve compliance and value of care

BACKGROUND

Care pathways facilitate standardized, evidence-based treatment to improve outcomes and value of care. Care pathways consist of multiple nodes representing decision points. Few studies investigate care pathway compliance. We demonstrate nodal care pathway analysis by reviewing compliance with our institutional multidisciplinary, evidence-based care pathways on the treatment of thyroid nodule to generate strategies to increase care pathway adherence and value of care.

METHODS

Patients undergoing workup and treatment of structural thyroid disease between January 2018 and June 2018 were included in a retrospective analysis of enterprise-wide compliance with the following 3 care pathway nodes: (1) laboratory testing: only patients with abnormal results from thyroid-stimulating hormone testing should have T3/T4 measured. (2) imaging: neck computed tomography, magnetic resonance imaging, and positron emission tomography ordered for the workup of nodules were reviewed to determine clinical appropriateness. (3) operative treatment: the first 200 thyroid resections conducted in 2018 were reviewed to determine whether the indication and extent of the operation complied with the care pathway. Medicare fee schedules were used for financial calculations.

RESULTS

Care pathway nonadherence occurred in 48% of the thyroid-stimulating hormone studies and 38% of the imaging studies obtained, with annual costs exceeding $120,000. Substantial care pathway nonadherence occurred in 3% of nodule-related operations.

CONCLUSION

Care pathway nodal analysis can identify areas of care pathway nonadherence. Nodal analysis should be considered for care pathway maintenance and generation of strategies of quality improvement.