Towards excellence in quality patient care: a clinical pathway for myocardial infarction

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials

Background

The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs.

Methods

An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported.

Results

Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base.

Conclusions

Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis

OBJECTIVE

To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals.

STUDY SELECTION

Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol.

DATA SYNTHESIS

Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86-0.96], in surgical (OR, 0.84; 95% CI, 0.80-0.89), and in medical patients (OR, 0.94; 95% CI, 0.94-0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56-0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36-0.67), respiratory failure (OR, 0.40; 95% CI, 0.27-0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62-0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79-0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62-0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55-0.86).

CONCLUSIONS

Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals' commitment to quality of medical care, likely contribute to the actual causal pathway.

Evidence‐based re‐engineering: re‐engineering the evidence

PURPOSE

Business process redesign (BPR) is used to implement organizational transformations towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully described and evaluated so that "best practices" can be re-applied. To investigate this, available evidence was collected on patient care redesign projects.

DESIGN/METHODOLOGY/APPROACH

The Ebsco Business Source Premier, Embase and Medline databases were searched. Studies on innovations related to re-engineering patient care that used before-after design as minimum prerequisites were selected. General characteristics, logistic parameters and other outcome measures to determine the objectives and results and interventions used were looked at.

FINDINGS

A total of 86 studies that conformed to the criteria were found: a minority mentioned measurable parameters in their objectives. In the majority of studies, multiple interventions were combined within single studies, making it impossible to compare the effects of individual interventions. Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the study objectives and the reported results. Many more issues were reported in the results than were mentioned in the study aims. It would appear that publications were hard to find owing to a lack of specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear and univocal research methods, terms and reporting guidelines are advisable and must be developed in order to learn and benefit from BPR innovations in health care organizations.

ORIGINALITY/VALUE

This appears to be the first time available evidence about redesign projects in hospitals has been systematically collected and assessed.

Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway

PURPOSE

The purpose of this analysis was to determine the adequacy of evolving national standardized terminologies with regard to coded data elements (concepts) in an automated clinical pathway designed to drive adherence with the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Evaluation and Management of Chronic Heart Failure.

METHOD

Concepts were identified in a previously developed automated clinical pathway and associated tools. Once identified, concepts were categorized according to the conceptual domains identified by Campbell et al. (1997). A review of evolving national standardized terminologies and coding systems was initiated to determine if the identified concepts had corresponding representation in one of these coding systems. Available codes were then evaluated for adequacy with respect to national guideline adherence measures put forth by the Centers for Medicare/Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

RESULTS

The concept domain model put forth by Campbell et al. (1997) worked well for organizing concepts and for providing a useful framework for data analysis. Using our method, 260 unique pathway concepts were identified, of which, 91.9% (239) are represented by one or more of the standardized coding systems. Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT alone represented 86.2% of the concepts. Seventy percent (70%) of the clinical pathway concepts are represented using the Health Insurance Portability and Accountability Act (HIPAA) mandated national terminologies alone. Less than 50% of CMS and JCAHO guideline adherence concepts were found to have representation in the HIPAA mandated terminologies. The addition of Logical Observation Identifier Names and Codes (LOINC) and SNOMED CT improved representation up to 86.4%, but did not include representation of all concepts necessary for complete electronic monitoring of guideline adherence.

CONCLUSIONS

Evolving national standardized terminologies provided matching terms for the majority of the data elements in the automated clinical pathway. Standard clinical terminologies with granular terms such as LOINC and SNOMED CT are required to represent the depth and detail of certain procedures and guideline-based care. Gaps exist in Health Insurance Portability and Accountability Act (HIPAA) mandated terminologies for representing interdisciplinary concepts in national adherence measures.

Clinical pathways in total knee arthroplasty: a New Zealand experience

PURPOSE

To ascertain the effects of a clinical pathway in our institution.

METHODS

This retrospective and comparative study was performed on all patients undergoing total knee arthroplasty over a 5-year period. This period covered the 30 months prior to the introduction of the pathway (group 1), and the 30 months following its introduction (group 2).

RESULTS

There was a significant reduction in the duration of hospital stay of group 2 patients (p<0.0001), with 62.8% of these patients staying less than 8 postoperative days. There was a reduction in the number of patients with thromboembolic complications (p<0.05) and no increase in overall complications or readmission rate. There was a trend to increased use of rehabilitation services among group 2 patients.

CONCLUSION

Clinical pathway implementation resulted in a significant reduction in the length of stay, and achieved a more efficient management of hospitalised patients without compromising outcome.