DRUGS System Improving the Effects of Clinical Pathways: A Systematic Study

The effectiveness of clinical pathway software in inpatient settings: A systematic review

BACKGROUND

Various studies have assessed the effectiveness of clinical pathways (CPs) in inpatient settings and provided systematic evidence that they positively affect patient outcomes and efficiency of care, thus lowering costs. In recent years, CP implementation is often combined or extended with clinical pathway software (CPS). Until now, no systematic literature review appears to exist which synthesizes the evidence on the effectiveness of CPS in inpatient settings, in relation to the CPs they support.

OBJECTIVES

The purpose of this study was to systematically review evidence on (perceived) effectiveness of clinical pathway software (CPS) and investigate mechanisms explaining the effects of CPS implementation on outcomes.

METHODS

We searched MEDLINE via PubMed and Scopus, for English-language original articles. Articles were included if they examined the effectiveness and/or the perceived effectiveness of CPS in the inpatient setting. They were analyzed for evidence on structure, process and outcome effects, as well as for mechanisms explaining such effects in relation to contextual factors.

RESULTS

From 2904 articles, 12 studies met our inclusion criteria. The seven studies reporting on adherence provide conclusive evidence that CPSs can improve adherence. We also found conclusive evidence of improvement of process related measures regarding appropriate diagnostics, timeliness of care, and length of stay (LOS). Evidence on costs and outcomes is weak and/or less conclusive. This holds true both for patient outcomes (e.g. mortality/patient satisfaction) and caregiver outcomes (e.g. user satisfaction). The studies presented no direct evidence on mechanisms explaining how CPS relate to process and outcome improvements.

CONCLUSIONS

The primary effects of CPS to increase adherence may in turn positively impact other process indicators such as LOS, timeliness of care, and diagnostic effectiveness. Subsequent effects on costs, outcomes for patients, physicians and nurses remain inconclusive and call for further research. Further research should explicitly take context into account. The scarce and weak evidence-base relating CPS implementation to process and outcome effects needs development along the same lines.

Review of methods and study designs of evaluations related to clinical pathways

Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.