Assessing clinical pathways use in a community hospital: it depends on what "use" means

Effects of Clinical Pathways: Do They Work?

Objective:

Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways.

Methods:

A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics.

Results:

A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways.

Conclusion:

On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.

Quality toolbox: clinical pathways can improve core measure scores

Clinical pathways (CPs) are decision-making tools designed to improve the quality of patient care processes and reduce costs. We conducted a retrospective analysis to determine whether multidisciplinary CPs had improved core measure scores. Comparative data to document secular trends were obtained from 45 Maryland hospitals. There were 6013 discharges with community-acquired pneumonia (CAP), congestive heart failure (CHF), or acute myocardial infarction (AMI) for the 3-year data collection period ending in 9/30/05. The 72.5% of cases in which CPs were employed to manage CAP, CHF, or AMI were significantly more likely to meet the Appropriate Care Measure (ACM) standards than the 26% that did not (81% vs. 67.8%, p < .001). Scores for all 10 ACM components for CP-managed patients were better than Maryland state averages. Improvements were stable over a 3-year period of time.

Isolation and gene expression analysis of Arabidopsis thaliana mutants with constitutive expression of ATL2, an early elicitor-response RING-H2 zinc-finger gene

Genes with unstable transcripts often encode proteins that play important regulatory roles. ATL2 is a member of a multigene family coding highly related RING-H2 zinc-finger proteins that may function as E3 ubiquitin ligases. ATL2 mRNA accumulation occurs rapidly and transiently after incubation with elicitors of pathogen response. We screened 50,000 M(2) families from a line that carries a fusion of pATL2 to the GUS reporter gene and isolated five mutants, which we named eca (expresión constitutiva de ATL2), that showed constitutive expression of the reporter gene. One mutant exhibits a drastic stunted phenotype while the other four grow similarly to wild type. Two early chitin-induced genes and known pathogenesis-related genes such as NPR1, PAL, and CHS are activated in all the mutants whereas members of the ATL family and PR-1 and PDF2.1, which are markers of the salicylic acid (SA) jasmonate (JA) defense-response pathways, display differential expression between the mutants. These observations indicate that the ECA gene products may function in the early steps of an elicitor-response pathway, although some of them may function at other stages on the SA or JA defense-response pathways. Likewise, the fact that ATL2 and other members of the ATL family are activated in eca mutants links the induction of this putative class of ubiquitin ligases to plant defense signaling pathways.

An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.

What are the initial perceptions of multidisciplinary personnel new to integrated care pathway development?

Initial perceptions of programmatic shifts are important to gauge if organizational change is to be successful. We used qualitative methods to understand the perceptions of multidisciplinary team members who were responsible for developing integrated care pathways for chronic heart disease in an attempt to improve continuity of care. Members viewed continuity of care as problematic and perceived ICPs as a template for increasing knowledge and enhancing communication. Numerous barriers to ICP use were noted. Information collected in this study may assist others who are developing integrated care pathways.

Barriers to successful implementation of a clinical pathway for CHF

Clinical pathways represent a strategy for responding to the current healthcare environment with a focus on managing care, reducing costs, increasing patient satisfaction, and improving quality. However, many healthcare organizations have found that implementing clinical pathways is not entirely successful even when they are based on sound evidence. The purpose of this case study was to describe and explain factors related to the success or failure of implementing a clinical pathway for congestive heart failure (CHF) patients in a 300-bed community hospital. The key factors involved in the nonadoption of the CHF pathway were inconsistencies in procedures and the work group culture.