Defining pathways

Development and validity testing of a matrix to evaluate maturity of clinical pathways: a case study in Saskatchewan, Canada

BACKGROUND

Healthcare systems are transforming into learning health systems that use data-driven and research-informed approaches to achieve continuous improvement. One of these approaches is the use of clinical pathways, which are tools to standardize care for a specific population and improve healthcare quality. Evaluating the maturity of clinical pathways is necessary to inform pathway development teams and health system decision makers about required pathway revisions or implementation supports. In an effort to improve the development, implementation, and sustainability of provincial clinical pathways, we developed a clinical pathways maturity evaluation matrix. To explore the initial content and face validity of the matrix, we used it to evaluate a case pathway within a provincial health authority in Saskatchewan, Canada.

METHODS

By using iterative consensus-based processes, we gathered feedback from stakeholders including patient and family partners, policy makers, clinicians, and quality improvement specialists, to rank, retain, or remove enablers and sub-enablers of the draft matrix. We tested the matrix on the Chronic Pain Pathway (CPP) for primary care in a local pilot area and revised the matrix based on feedback from the CPP development team leader.

RESULTS

The final matrix contains five enablers (i.e., Design, Ownership and Performer, Infrastructure, Performance Management, and Culture), 20 sub-enablers, and three trajectory definitions for each sub-enabler. Supplemental documents were created for six sub-enablers. The CPP scored 15 out of 40 possible points of maturity. Although the pathway scored highest in the Design enabler (10/12), it requires more attention in several areas, specifically the Ownership and Performer and the Performance Management enablers, each of which scored zero. Additionally, the Infrastructure and Culture enablers scored 2/4 and 3/8 points, respectively. These areas of the CPP are in need of improvement in order to enhance the overall maturity of the CPP.

CONCLUSIONS

We developed a clinical pathways maturity matrix to evaluate the various dimensions of clinical pathways' development and implementation. The goals of this initial work were to develop and validate a tool to assess the maturity and readiness of new or existing pathways and to track pathways' revisions and improvements.

Mental health clinical pathways for children and young people with long-term health conditions: A systematic review

RATIONALE

Clinical pathways (CPWs) are structured care plans that set out essential steps in the care of patients with a specific clinical problem. Amidst calls for the prioritisation of integrated mental and physical health care for young people, multidisciplinary CPWs have been proposed as a step towards closer integration. There is very limited evidence around CPWs for young people with mental and physical health needs, necessitating a review of the literature.

AIMS AND OBJECTIVES

The aim of this review is to understand how clinical pathways have been used to deliver mental health support to children and young people with long-term physical health conditions and their effectiveness across a range of outcomes.

METHODS

The databases MEDLINE, CENTRAL, PsycINFO and CINAHL were searched from inception to 6 September 2023. Keywords linked to children and young people, mental health, long-term physical health conditions and CPWs were used. Studies using either quantitative or qualitative research designs were included. All studies must have evaluated a CPW to provide mental health support to children and young people (up to 25 years old) with long-term health physical conditions. Both mental and physical health outcomes were considered. Pathways were grouped by integration 'model' as described in the wider literature.

RESULTS

The initial search returned 4082 studies after deduplication. A total of eight studies detailing six distinct care pathways (232 participants [170 children and young people; 50 caregivers; 12 healthcare professionals]) met eligibility criteria and were included in the analysis. Four pathways were conducted within an 'integrated model'; two were a combination of 'integrated' and 'colocated'; and none within a 'co-ordinated model'. Only pathways within an integrated model reported quantitative health outcomes, with improvements across a range of mental health measures. One negative physical health outcome was reported from an integrated diabetes pathway, but this should be interpreted with caution.

CONCLUSION

This review identified a range of CPW designs but most fell under an integrated model. The results suggest that calls for integrated mental health pathways in this population may be appropriate; however, conclusions are limited by a paucity of evidence.

Clinical pathways for Korean medicine: An implementation approach to impact on the clinical process and association with attitudes

Background

South Korea's Ministry of Health and Welfare has developed clinical pathways for Korean Medicine (KM-CPs). As part of this initiative, a panel comprising Korean Medicine doctors (KMD) was assembled. This implementation study aimed to preliminarily explore how KM-CP implementation affects the appropriateness and efficiency of the clinical process and its relation to attitude.

Methods

Through random sampling, 311 KMDs were recruited as panelists to participate in two surveys. The surveys included information regarding the KM clinical environment and KM-CP implementation. A panel management program and educational materials were provided to KMDs between the two survey periods. Only 262 KMDs who responded to both surveys were included in the analysis. Three analyses were conducted: 1) descriptive analysis of the study variables, 2) panel analysis using the ordered logit regression model to elucidate the impact of KM-CP on the appropriateness and efficiency of the clinical process, and 3) ordered logit regression analysis of the association between KM-CP implementation and attitude.

Results

More than two-thirds of the KMDs attempted to adopt KM-CP, with mostly positive perception expressed by these doctors. However, expectations and concerns coexist with the standardization of KM-CP. Cases in which KM-CPs were partially and mostly implemented respectively had negative and positive effects on the appropriateness and efficiency of the clinical process compared to those in which KM-CPs were not implemented. Compared to neutral attitude, positive and very positive attitudes tended to be associated with increased implementation of KM-CP. However, statistical significances were not observed.

Conclusions

The impact of KM-CP on the clinical process and its association with attitude were found to be statistically unclear or inconsistent. Considering the study limitations and implications, we suggest a policy and academic strategies aimed at fostering improvement to enhance its utility.

Lessons learned from the experiences of patients with chronic pelvic pain syndrome (CPP syndrome) with a multidisciplinary consultation: a qualitative study

INTRODUCTION

Chronic pelvic pain syndrome is a complex multifactorial condition with an increasing prevalence probably due to a rising awareness. Chronic pelvic pain syndrome is pain in the pelvic area and often accompanied with complaints in other organ systems of the lesser pelvis. Patients with chronic pelvic pain syndrome who present at our center are evaluated in a standardized care pathway with an integrated multidisciplinary consultation. The team works in a single center and consists of gynecologists, pain specialists, urologists, a pelvic floor physiotherapist and a psychologist. The aim of this interview study is to evaluate the value of the multidisciplinary consultation from the patient's perspectives.

METHODS

In a qualitative study, we evaluated the experiences and perspectives of patients with chronic pelvic pain syndrome concerning the multidisciplinary consultation at the Radboud University Medical Center. Semistructured interviews were conducted with patients with chronic pelvic pain syndrome who attended a multidisciplinary consultation between 2019 and 2022. All interviews were transcribed verbatim, coded and analyzed via ATLAS.ti with the conventional content analysis.

RESULTS

Data saturation was reached after seven interviews, followed by three confirmative interviews. In total, 10 patients (22-76 years) participated in the study. Three relevant themes were identified in the interviews: the deleterious effects of pain on overall health, the importance of the design of the multidisciplinary consultation, and the performance of healthcare professionals (knowledge, skills and interaction with patients and colleagues). Participants suggested that although the consultation did not improve their pain experience, there was value in having a comprehensive assessment of their disease. Patients preferred the consultation to occur at the beginning of the care. Additionally, they acknowledged the performance of healthcare providers and having their complaints recognized. However, some participants suggested the need for additional attention to mental health issues during the multidisciplinary consultation.

DISCUSSION

Even though patients did not perceive the multidisciplinary consultation to improve their pain experience, they appreciated the sense of recognition by this team.

CONCLUSION

A multidisciplinary consultation is of value from the patients' perspective. A suggestion for improvement emerged where the multidisciplinary consultation should occur at the beginning of the patient journey.

Patient Satisfaction and Experience with Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: A Mixed-Methods study

INTRODUCTION

Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is a safe and effective healthcare pathway. However, there is limited understanding of the patient perspective on SDD. The aim of this study was to explore patient satisfaction and experience with SDD after RYGB.

METHODS

A mixed-methods study with a concurrent design was conducted in a Dutch teaching hospital, using questionnaires and interviews. Patients who underwent RYGB and were discharged on the day of the surgery completed four questionnaires of the BODY-Q (satisfaction with the surgeon, satisfaction with the medical team, satisfaction with the office staff, and satisfaction with information provision) ± 4 months postoperative. The results of the questionnaires were compared with pre-existing data from a cohort of patients who stayed overnight after surgery (i.e., control group). A subset of patients was individually interviewed for an in-depth understanding of the patient perspective on SDD.

RESULTS

In the questionnaires, median scores for the control group (n = 158) versus the present group of patients (n = 51) were as follows: 92/100 vs. 92/100 (p = 0.331) for the surgeon, 100/100 vs. 92/100 (p = 0.775) for the medical team, 100/100 vs. 100/100 (p = 0.616) for the office staff, and 90/100 vs. 73/100 (p = 0.015) for information provision. Interviews with 14 patients revealed seven themes, describing high satisfaction, along with several points of interest.

CONCLUSIONS

Patient satisfaction with SDD after RYGB is high, although information provision regarding the day of surgery could be improved. However, not every medically eligible patient might be suitable for this healthcare pathway, as responsibilities are shifted.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Trauma Assessment Clinic: A virtual fracture clinic model that delivers on its PROMise!

BACKGROUND

The use of virtual fracture clinics across the United Kingdom and Ireland is growing and have been shown in an increasing number of studies to be safe, cost-effective and associated with good functional outcomes and patient satisfaction rates for certain fracture types. Initially pioneered at Glasgow Royal Infirmary, many centres have adopted similar templates, or variations of, and the overall aim of this study was to assess functional outcomes and injury recovery satisfaction rates of patients discharged directly following review in a specific virtual fracture clinic model known as the Trauma Assessment Clinic (TAC).

METHODS

A prospective observational study was carried out of paediatric (aged <17 years) and adult (aged >17 years) patients, with the five most commonly observed fracture types, who were discharged directly following review at the TAC in a single hospital centre over a 12 month period from January to December 2018. Primary and secondary outcomes were assessed via telephone administered questionnaires and patient reported outcome measures (PROMs).

RESULTS

A total of 198 patients were included in the study (n = 98 paediatric and n = 100 adult). Overall, 192 (97%) patients or parents/guardians of patients stated that they either strongly agreed (n = 148, 74.9%) or agreed (n = 44, 22.1%) that they were satisfied with their own or their child's recovery from their injury at a median follow-up of 9 months post direct discharge from the TAC. Adult patients had an EQ-5D-5L index median value of 1 (range 0-1), an EQ-VAS median of 87 (range 0-100), a QuickDASH median score of 0 (range 0-100) and a median LEFS of 80 (range 0-80).

CONCLUSION

The virtual management of trauma patients via the TAC model is a safe and patient-centred approach to treating certain injuries and fracture patterns. This study reports excellent patient reported outcome measures and patient injury recovery satisfaction rates. The use of current available technology in tandem with up-to-date best clinical practice and guidelines play a central role in this novel care pathway.

Building digital patient pathways for the management and treatment of multiple sclerosis

Recent advances in the field of artificial intelligence (AI) could yield new insights into the potential causes of multiple sclerosis (MS) and factors influencing its course as the use of AI opens new possibilities regarding the interpretation and use of big data from not only a cross-sectional, but also a longitudinal perspective. For each patient with MS, there is a vast amount of multimodal data being accumulated over time. But for the application of AI and related technologies, these data need to be available in a machine-readable format and need to be collected in a standardized and structured manner. Through the use of mobile electronic devices and the internet it has also become possible to provide healthcare services from remote and collect information on a patient's state of health outside of regular check-ups on site. Against this background, we argue that the concept of pathways in healthcare now could be applied to structure the collection of information across multiple devices and stakeholders in the virtual sphere, enabling us to exploit the full potential of AI technology by e.g., building digital twins. By going digital and using pathways, we can virtually link patients and their caregivers. Stakeholders then could rely on digital pathways for evidence-based guidance in the sequence of procedures and selection of therapy options based on advanced analytics supported by AI as well as for communication and education purposes. As far as we aware of, however, pathway modelling with respect to MS management and treatment has not been thoroughly investigated yet and still needs to be discussed. In this paper, we thus present our ideas for a modular-integrative framework for the development of digital patient pathways for MS treatment.

Optimization of Care Pathways Through Technological, Clinical, Organizational and Social Innovations: A Qualitative Study

Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action.

Exploring Acute Pancreatitis Clinical Pathways Using a Novel Process Mining Method

Mining process models of medical behavior from electronic medical records is an effective way to optimize clinical pathways. However, clinical medical behavior is an extremely complex field with high nonlinearity and variability, and thus we need to adopt a more effective method. In this study, we developed a fuzzy process mining method for complex clinical pathways. Firstly, we designed a multi-level expert classification system with fuzzy values to preserve finer details. Secondly, we categorized medical events into long-term and temporary events for more specific data processing. Subsequently, we utilized electronic medical record (EMR) data of acute pancreatitis spanning 9 years, collected from a large general hospital in China, to evaluate the effectiveness of our method. The results demonstrated that our modeling process was simple and understandable, allowing for a more comprehensive representation of medical intricacies. Moreover, our method exhibited high patient coverage (>0.94) and discrimination (>0.838). These findings were corroborated by clinicians, affirming the accuracy and effectiveness of our approach.

How to Use Lean Thinking for the Optimization of Clinical Pathways: A Systematic Review and a Proposed Framework to Analyze Pathways on a System Level

Lean Thinking and clinical pathways are commonly used concepts to improve healthcare. However, little is known on how to use Lean Thinking for the optimization of pathways or the quantification of both concepts. This study aims to create a framework to analyze pathways with Lean Thinking on a system level, by quantifying the seven wastes, flow and pull. A systematic literature review was performed. Inclusion criteria were the focus of the article on a well-defined group of patients and studied a pathway optimization with Lean Thinking. Data were extracted on measured outcomes, type of intervention and type of researched pathway. Thirty-six articles were included. No articles described the implementation of the Lean Thinking philosophy or studied the development of their people and partners ("4 P" model). Most articles used process optimization tools or problem-solving tools. The majority of the studies focused on process measures. The measures found in the review were used as input for our suggested framework to identify and quantify wastes, flow, and pull in a clinical pathway. The proposed framework can be used to create an overview of the improvement potential of a pathway or to analyze the level of improvement after an enhancement is introduced to a pathway. Further research is needed to study the use of the suggested quantifications.

Application of critical pathway of integrative medical service for lumbar herniated nucleus pulposus: A protocol for single-centered prospective observational study

BACKGROUND

Lumbar herniated nucleus pulposus (L-HNP) is a condition in which fibroblasts escape due to degenerative changes or external forces in the intervertebral disc, causing neurological symptoms by compressing the dura mater or nerve root.

OBJECTIVES

The purpose of this study is to analyze and compare the effectiveness, economic feasibility, and safety of using an integrated medical service critical pathway (CP) in L-HNP patients.

METHODS

This single-center prospective observational study will be performed at Kyung Hee University Medicine Hospital and Kyung Hee University Korean Medicine Hospital. The inclusion criteria are a diagnosis of L-HNP on magnetic resonance imaging or computed tomography scans, age under 80 years, a visual analog scale score of 7 or higher for either lower back pain or lower extremity pain. The included 102 participants will be classified into 6 groups (n = 17 in each group): CP application with conservative treatment; CP application with open discectomy; CP application with intrabody fusion; conservative treatment without CP application; open discectomy without CP application; and interbody fusion without CP application. We will collect data on the visual analog scale, ODI, SF-36, and EQ-5D-3L scores; number of admission days; medical staff satisfaction; patients health service satisfaction; waiting time for consultations; use of pain relievers; and CP application and completion rates.

CONCLUSION

In future, this study is expected to serve as a basis for follow-up studies on the development and application of CPs in integrated medical services for various diseases, including lumbar herniated nucleus pulposus.

Geriatric rehabilitation care after hip fracture

PURPOSE

After acute hospital admission, patients with a hip fracture are frequently discharged to skilled nursing homes providing geriatric rehabilitation (GR). There are few evidence-based studies regarding specific treatment times and assessments during GR. This study aims to provide a description of care for hip fracture patients during GR in the Netherlands.

METHODS

Descriptive study analyzing the care pathways from GR facilities, regarding healthcare professionals involved, allocated treatment time per profession, total length of rehabilitation stay, and assessment instruments. Based on the reimbursement algorithm (diagnostic treatment combination = DBCs), of 25 patients, the registered actual treatment time per profession was calculated.

RESULTS

The care pathways pivoted on three groups of health care professionals: medical team (MT), physiotherapy (PT), and occupational therapy (OT). There was some discrepancy between the allocated time in the care pathways and the calculated mean actual treatment time from the DBCs. First week: MT 120-180 min, DBC 120 (SD: 59) minutes; PT 120-230 min, DBC 129 (SD: 58) minutes; and OT 65-165 min, DBC 93 (SD: 61) minutes. From week two onwards, MT 15-36 min, DBC 49 (SD: 29) minutes; PT 74-179 min, DBC 125 (SD: 50) minutes; and OT 25-60 min, DBC 47 (SD: 44) minutes. Dieticians, psychologists, and social workers were sporadically mentioned. There was heterogeneity in the assessment and screening tools.

CONCLUSIONS

It is difficult to define current standard care in GR after hip fracture in the Netherlands due to the diversity in care pathways and large practice variation. This is a problem in conducting randomized effectiveness research with care provided as control.

TRIAL REGISTER AND DATE OF REGISTRATION

NL7491 04-02-2019.

Establishing a Multicenter Network for Patients With Thyroid Nodules and Cancer: Effects on Referral Patterns

OBJECTIVE

To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer.

METHODS

This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network.

RESULTS

Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network (P = .001), while patient referrals remained stable (n = 108 to 106). Qualitative evaluation indicated that the uniform care pathway and the regional multidisciplinary tumor board were valued high.

DISCUSSION

Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists.

IMPLICATIONS FOR PRACTICE

The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.

Exploring sustainable care pathways - a scoping review

BACKGROUND

Patients with mental health problems experience numerous transitions into and out of hospital.

AIM

The review studies assessing clinical care pathways between psychiatric hospitalization and community health services.

METHODS

We used publications between 2009-2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community.

RESULTS

Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care.

RESOURCES

Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need.

ETHICAL ISSUES

Respectful communication and patient-centred, non-humiliating care.

CONCLUSIONS

System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication.

Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies

BACKGROUND

A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation.

METHODS

We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospital-wide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies.

RESULTS

The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection.

CONCLUSION

Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature.

Provision of acute care pathways for older major trauma patients in the UK

BACKGROUND

The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known.

OBJECTIVE

The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK.

METHODS

A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each.

RESULTS

Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age.

CONCLUSIONS

This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Business Process Model and Notation and openEHR Task Planning for Clinical Pathway Standards in Infections: Critical Analysis

Background

Clinical pathways (CPs) are usually expressed by means of workflow formalisms, providing health care personnel with an easy-to-understand, high-level conceptual model of medical steps in specific patient conditions, thereby improving overall health care process quality in clinical practice. From a standardized perspective, the business process model and notation (BPMN), a widely spread general-purpose process formalism, has been used for conceptual modeling in clinical domains, mainly because of its easy-to-use graphical notation, facilitating the common understanding and communication of the parties involved in health care. However, BPMN is not particularly oriented toward the peculiarities of complex clinical processes such as infection diagnosis and treatment, in which time plays a critical role, which is why much of the BPMN clinical-oriented research has revolved around how to extend the standard to address these special needs. The shift from an agnostic, general-purpose BPMN notation to a natively clinical-oriented notation such as openEHR Task Planning (TP) could constitute a major step toward clinical process improvement, enhancing the representation of CPs for infection treatment and other complex scenarios.

Objective

Our work aimed to analyze the suitability of a clinical-oriented formalism (TP) to successfully represent typical process patterns in infection treatment, identifying domain-specific improvements to the standard that could help enhance its modeling capabilities, thereby promoting the widespread adoption of CPs to improve medical practice and overall health care quality.

Methods

Our methodology consisted of 4 major steps: identification of key features of infection CPs through literature review, clinical guideline analysis, and BPMN extensions; analysis of the presence of key features in TP; modeling of relevant process patterns of catheter-related bloodstream infection as a case study; and analysis and proposal of extensions in view of the results.

Results

We were able to easily represent the same logic applied in the extended BPMN-based process models in our case study using out-of-the-box standard TP primitives. However, we identified possible improvements to the current version of TP to allow for simpler conceptual models of infection CPs and possibly of other complex clinical scenarios.

Conclusions

Our study showed that the clinical-oriented TP specification is able to successfully represent the most complex catheter-related bloodstream infection process patterns depicted in our case study and identified possible extensions that can help increase its adequacy for modeling infection CPs and possibly other complex clinical conditions.

Dilemmas and deliberations in managing the care trajectory of elderly patients with complex health needs: a single-case study

Background

Today, the ageing population is larger than ever before, and people who are living longer with chronic illnesses and multimorbidity need support from multiple healthcare service levels. Similarly, healthcare systems are becoming increasingly specialised and fragmented. The World Health Organization has highlighted novel policies for developing integrated and person-centred services. However, patients, next of kin and health professionals face several challenges in managing healthcare during the care trajectory. Limited literature has addressed the challenges experienced by these groups. Therefore, this study aimed to identify the dilemmas and deliberations faced by patients, next of kin and health professionals during the care trajectory of elderly patients with complex healthcare needs.

Method

The study had a qualitative single-case design. The case was taken from a multi-case study exploring the care trajectory of elderly patients. The participants were the patient, their next of kin and the health professionals involved in the patient’s care trajectory. Data were obtained via observation and individual interviews conducted during the patient’s hospital stay and after the patient returned home.

Results

The dilemmas and deliberations in managing the care trajectory were divided into four main themes: the health professionals’ pursuit of appropriate and feasible healthcare services, the next of kin’s planning horizons, being the person left in limbo and reorganising the home for comprehensive healthcare.

Conclusion

The pursuit of a tailored and suitable healthcare service lead to a comprehensive mobilisation of and work by all actors involved. Having a comprehensive understanding of these conditions are of importance in developing an appropriate care trajectory for the elderly patient with complex need.

Inverse optimization on hierarchical networks: an application to breast cancer clinical pathways

Clinical pathways are standardized processes that outline the steps required for managing a specific disease. However, patient pathways often deviate from clinical pathways. Measuring the concordance of patient pathways to clinical pathways is important for health system monitoring and informing quality improvement initiatives. In this paper, we develop an inverse optimization-based approach to measuring pathway concordance in breast cancer, a complex disease. We capture this complexity in a hierarchical network that models the patient's journey through the health system. A novel inverse shortest path model is formulated and solved on this hierarchical network to estimate arc costs, which are used to form a concordance metric to measure the distance between patient pathways and shortest paths (i.e., clinical pathways). Using real breast cancer patient data from Ontario, Canada, we demonstrate that our concordance metric has a statistically significant association with survival for all breast cancer patient subgroups. We also use it to quantify the extent of patient pathway discordances across all subgroups, finding that patients undertaking additional clinical activities constitute the primary driver of discordance in the population.

The Effect of Care Pathways on Coronary Care Nurses: A Preliminary Study

BACKGROUND AND OBJECTIVES

A care pathway is a structured care plan based on best clinical practice for a particular patient group. It reorganizes a complex process by providing structured, standardized care and supportive multidisciplinary teamwork. Although care pathways are used worldwide, the impact and benefit of a care pathway for coronary care practices have been minimally debated. This preliminary study aimed to examine the effect of a care pathway on the autonomy, teamwork, and burnout levels among coronary care nurses in a tertiary hospital.

METHODS

A preliminary study was conducted using a pre/posttest one-group quasi-experimental design. A self-administered questionnaire was provided to 37 registered nurses from the cardiac ward of a tertiary hospital. The care pathway was developed on the basis of the current literature, local guidelines, and expert panel advice. The autonomy, teamwork, and burnout levels at the beginning and 4 months after disseminating the care pathway were measured. Implementing the care pathway included educational sessions, training in using the care pathway, and site visits to monitor nursing practices.

RESULTS

Most of the respondents were female (94.6%; n = 35), the median age of the respondents was 26.5 years (interquartile range [IQR] = 23-31), and the median length of the clinical experience was 4 years (IQR = 2-8). A statistically significant reduction in the mean burnout score was observed (mean of 58.12 vs 52.69, P < .05). A slight improvement in autonomy level was found, although it was not statistically significant. No statistically significant improvement was found in the teamwork levels.

CONCLUSION

The care pathway was associated with reduced nurse burnout. The results showed a slight improvement in autonomy level among coronary care nurses after implementing the care pathway. From a practical viewpoint, the current study can help policy makers and managers reduce burnout. This study highlights the importance of using care pathways as a tool to reorganize the care process and improve the working environment. Managers must support nursing decisions and provide continuous education to enhance nurses' autonomy, which may increase understanding of respective roles, leading to higher levels of teamwork. However, with a small sample size, caution must be applied, as the findings might not be generalizable.

Benefits and limitations of business process model notation in modelling patient healthcare trajectory: a scoping review protocol

INTRODUCTION

The adoption of business process model notation (BPMN) in modelling healthcare trajectory can enhance the efficiency and efficacy of healthcare organisations, improve patient outcomes while restraining costs. Existing systematic reviews have been inconclusive regarding the effectiveness of BPMN in modelling healthcare trajectory. The aims of this scoping review are to map and aggregate existing evidence on the benefits and limitations associated with BPMN in healthcare trajectory, highlighting areas of improvement on BPMN and its extensions in healthcare. We will assess BPMN's ability to model key dimensions or concepts of the healthcare process and to meet the needs of stakeholders. The review will highlight the advantages of this approach to support clinical activities and decision-making processes associated with the healthcare trajectory, proposing a conceptual framework for improving the use of BPMN in healthcare.

METHODS AND ANALYSIS

This study will be performed in accordance with the methodological framework suggested by Arksey and O'Malley. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design focusing on the application of the BPMN approach for optimising healthcare trajectories, published in either English or French from 1 January 2004 to 9 December 2021. Two reviewers will independently screen titles, abstracts and full-text articles and select articles meeting the inclusion criteria. A customised data extraction form will be used to extract data. The results will be presented using descriptive statistics and thematic analysis on qualitative data.

ETHICS AND DISSEMINATION

Research ethics approval is not required. Review findings will be used to advance understanding about BPMN, its extensions and application in healthcare trajectory optimisation. The review will develop recommendations on tailoring BPMN strategies for optimising care pathways and decision-making processes. Findings will be disseminated in peer-reviewed journals, conferences and discussions with relevant organisations and stakeholders.

Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review

BACKGROUND

Confusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework.

METHODS

An innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed.

RESULTS

Forty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management.

CONCLUSIONS

This study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.

Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology

BACKGROUND

Diagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space.

METHODS

Qualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care.

RESULTS

Five themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption.

CONCLUSIONS

Care pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

Machine learning for classification of postoperative patient status using standardized medical data

BACKGROUND AND OBJECTIVE

Real-world evidence is defined as clinical evidence regarding the use and potential benefits or risks of a medical product derived from real-world data analyses. Standardization and structuring of data are necessary to analyze medical real-world data collected from different medical institutions. An electronic message and repository have been developed to link electronic medical records in this research project, which has simplified the data integration. Therefore, this paper proposes an analysis method and learning health systems to determine the priority of clinical intervention by clustering and visualizing time-series and prioritizing patient outcomes and status during hospitalization.

METHODS

Common data items for reimbursement (Diagnosis Procedure Combination [DPC]) and clinical pathway data were examined in this project at each participating institution that runs the verification test. Long-term hospitalization data were analyzed using the data stored in the cloud platform of the institutions' repositories using multiple machine learning methods for classification, visualization, and interpretation.

RESULTS

The ePath platform contributed to integrate the standardized data from multiple institutions. The distribution of DPC items or variances could be confirmed by clustering, temporal tendency through the directed graph, and extracting variables that contributed to the prediction and evaluation of SHapley Additive Explanation effects. Constipation was determined to be the risk factor most strongly related to long-term hospitalization. Drainage management was identified as a factor that can improve long-term hospitalization. These analyses effectively extracted patient status to provide feedback to the learning health system.

CONCLUSIONS

We successfully generated evidence of medical processes by gathering patient status, medical purposes, and patient outcomes with high data quality from multiple institutions, which were difficult with conventional electronic medical records. Regarding the significant analysis results, the learning health system will be used on this project to provide feedback to each institution, operate it for a certain period, and analyze and re-evaluate it.

Provider and Manager Perspectives on the Use of an Integrated Clinical Pathway for Community-Dwelling Older Adults: A Qualitative Case Study

Background:

Integrated care pathways (ICPs) could improve the organisation and delivery of care for community dwelling older adults. An ICP was developed and implemented in Québec to support home care processes. This study explores the perspectives of home care staff on the use of an ICP to support the organisation and delivery of health and social care to community-dwelling older adults with complex needs.

Theory and Methods:

A case study based on eleven semi-structured interviews and analysis of documents was carried out in an urban home care unit. The Normalization Process Theory was used for mixed thematic analysis.

Results:

While its capacity to store data and enhance interprofessional information exchange was appreciated by home care staff, the broad scope, and automated features of the ICP tool were often problematic. Concerns about increased provider workloads, disruption to provider-client relationships during clinical encounters, and difficulties engaging clients in decision-making were main obstacles in the use of the ICP.

Conclusion:

Given the importance of ICPs in advancing clinical integration, it is critical to continuously adjust their design to align with providers’ realities in order to optimize their potential in real life contexts.

When patients get stuck: A systematic literature review on throughput barriers in hospital-wide patient processes

Hospital productivity is of great importance to policymakers, and previous research demonstrates that improved hospital productivity can be achieved by directing more focus towards patient throughput at healthcare organizations. There is also a growing body of literature on patient throughput barriers hampering the flow of patients. These projects rarely, however, encompass complete hospitals. Therefore, this paper provides a systematic literature review on hospital-wide patient process throughput barriers by consolidating the substantial body of studies from single settings into a hospital-wide perspective. Our review yielded a total of 2207 articles, of which 92 were finally selected for analysis. The results reveal long lead times, inefficient capacity coordination and inefficient patient process transfer as the main barriers at hospitals. These are caused by inadequate staffing, lack of standards and routines, insufficient operational planning and a lack in IT functions. As such, this review provides new perspectives on whether the root causes of inefficient hospital patient throughput are related to resource insufficiency or inefficient work methods. Finally, this study develops a new hospital-wide framework to be used by policymakers and healthcare managers when deciding what improvement strategies to follow to increase patient throughput at hospitals.

Association Between Rapid Response Algorithms and Clinical Outcomes of Hospitalized Children

OBJECTIVES

To evaluate whether the implementation of clinical pathways, known as pediatric rapid response algorithms, within an existing rapid response system was associated with an improvement in clinical outcomes of hospitalized children.

METHODS

We retrospectively identified patients admitted to the PICU as unplanned transfers from the general medical and surgical floors at a single, freestanding children's hospital between July 1, 2017, and January 31, 2020. We examined the impact of the algorithms on the rate of critical deterioration events. We used multivariable Poisson regression and an interrupted time series analysis to measure 2 possible types of change: an immediate implementation effect and an outcome trajectory over time.

RESULTS

We identified 892 patients (median age: 4 [interquartile range: 1-12] years): 615 in the preimplementation group, and 277 in the postimplementation group. Algorithm implementation was not associated with an immediate change in the rate of critical deterioration events but was associated with a downward rate trajectory over time and a postimplementation trajectory that was significantly less than the preimplementation trajectory (trajectory difference of -0.28 events per 1000 non-ICU patient days per month; 95% confidence interval -0.40 to -0.16; P < .001).

CONCLUSIONS

Algorithm implementation was associated with a decrease in the rate of critical deterioration events. Because of the study's observational nature, this association may have been driven by unmeasured confounding factors and the chosen implementation point. Nevertheless, the results are a promising start for future research into how clinical pathways within a rapid response system can improve care of hospitalized patients.

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions

PURPOSE

In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country's needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.

METHODS

In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway.

RESULTS

The Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country's immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.

DISCUSSION/CONCLUSION

In Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways.

LEVEL OF EVIDENCE

Level III.

Rapid evidence review to understand effective frailty care pathways and their components in primary and community care

Purpose

Different pathways of frailty care to prevent or delay progression of frailty and enable people to live well with frailty are emerging in primary and community care in the UK. The purpose of the study is to understand effective frailty care pathways and their components to inform future service development and pathway evaluation in primary- and community-care services.

Design/methodology/approach

A rapid evidence review was conducted: 11 research publications met the inclusion criteria and were analysed using narrative thematic synthesis.

Findings

There is strong evidence that resistance-based exercise, self-management support, community geriatric services and hospital at home (HAH) improve patient health and function. In general, evaluation and comparison of frailty care pathways, components and pathway operations is challenging due to weaknesses, inconsistencies and differences in evaluation, but it is essential to include consideration of process, determinant and implementation of pathways in evaluations.

Originality/value

To achieve meaningful evaluations and facilitate comparisons of frailty pathways, a standardised evaluation toolkit that incorporates evaluation of how pathways are operated is required for evaluating the impact of frailty pathways of care.

BPM Support for Patient-Centred Clinical Pathways in Chronic Diseases

Epidemiological trends over the past decade show a significant worldwide increase in the burden of chronic diseases. At the same time, the human resources of health care are becoming increasingly scarce and expensive. One of the management concepts that can help in solving this problem is business process management (BPM). The results of research conducted in the healthcare sector thus far prove that BPM is an effective tool for optimizing clinical processes, as it allows for the ongoing automatic tracking of key health parameters of an individual patient without the need to involve medical personnel. The aim of this article is to present and evaluate the redesign of diagnostic and therapeutic processes enabling the patient-centric organization of therapy thanks to the use of new telemedicine techniques and elements of hyperautomation. By using an illustrative case study of one of the most common chronic diseases, Chronic Obstructive Pulmonary Disease (COPD), we discuss the use of clinical pathways (CPs) prepared on the basis of the current version of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as a communication tool between healthcare professionals, the patient and his or her caregivers, as well as the method of identifying and verifying new knowledge generated on an ongoing basis in diagnostic and therapeutic processes. We also show how conducting comprehensive, patient-focused primary health care relieves the health care system, and at the same time, thanks to the use of patient engagement and elements of artificial intelligence (predictive analyses), reduces the significant clinical risk of therapy.

Pediatric rapid response system innovations

Rapid Response Systems (RRSs) are an organizational approach to support the timely recognition and treatment of decompensating patients and are used in many pediatric hospitals. These systems are comprised of afferent and efferent Limbs, as well as oversight arms. When incorporated into an RRS, standardized care algorithms can be helpful in identifying deteriorating patients and improving behaviors of the multidisciplinary team. The aim of this paper is to provide an overview of pediatric RRS and provide an example in which standardized care algorithms developed for the efferent limb of a pediatric RRS were associated with improvement in early escalation of care.PLAIN LANGUAGE SUMMARYThe Rapid Response System (RRS) is used in hospitals to recognize and care for hospitalized patients that are decompensating outside of an Intensive Care Unit. RRSs are made up of two main response components. The afferent limb focuses on the recognition and calls for help; the efferent limb focuses on correcting the deteriorating patient's physiology. Much energy has been put into afferent limb development to identify worsening patients before they progress to full cardiac or respiratory arrest. Standardization of efferent limb care algorithms can assist in developing and maintaining a shared mental model of care to improve communication and function of the multidisciplinary team.

Integrated care pathways in neurosurgery: A systematic review

Introduction

Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success.

Methods

Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded.

Results

Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods

Conclusions

ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.

Implementing a Care Pathway for Complex Chronic Patients from a Nursing Perspective: A Qualitative Study

A care pathway constitutes a complex care strategy for decision-making and the organization of processes in the care of complex chronic patients, avoiding the fragmentation of care. Health professionals play a decisive role in the implementation, development, and evaluation of care pathways. This study sought to explore nurses’ opinions on the care pathway for complex chronic patients three years after its implementation. The study participants were thirteen nurses with different roles who were involved in the care pathway. Thematic content analysis of the semi-structured interviews resulted in four major themes: (a) the strengths of the route; (b) the impact of the route on caregivers; (c) the weaknesses of the route; and (d) the future of the route. Overall, the pathway was positively valued for the benefits it provides to patients, the caregiver, and the administration of professional health care. Participants voiced their concerns regarding: communication and coordination difficulties among professionals across the different levels of care, the need for improved teamwork and consensus among professionals at the same center, and human and material resources. The ongoing evaluation and monitoring of facilitators and barriers is necessary throughout the implementation process, to ensure continuity and quality of care in the health system.

Developing a Data-Driven Approach in Order to Improve the Safety and Quality of Patient Care

Objective: To improve the safety and quality of patient care in hospitals by shaping clinical pathways throughout the patient journey.

Study Setting: A risk model designed for healthcare organizations in the context of the challenges arising from comorbidity and other treatment-related complexities.

Study Design: The core of the model is the patient and his intra-hospital journey, which is analyzed using a data-driven approach. The structure of a predictive model to support organizational and clinical decision-making activities is explained. Data relating to each step of the intra-hospital journey (from hospital admission to discharge) are extracted from clinical records.

Principal Findings: The proposed approach is feasible and can be used effectively to improve safety and quality. It enables the evaluation of clinical risks at each step of the patient journey.

Conclusion: Based on data from real cases, the model can record and calculate, over time, variables and behaviors that affect the safety and quality of healthcare organizations. This provides a greater understanding of healthcare processes and their complexity which can, in turn, advance research relating to clinical pathways and improve strategies adopted by organizations.

Hypertensive disorders of pregnancy (HDP) management pathways: results of a Delphi survey to contextualise international recommendations for Indonesian primary care settings

Background

Hypertensive disorders of pregnancy (HDP) are a significant contributor to the high maternal mortality rate in Indonesia. At the moment, limited guidelines are available to assist primary care providers in managing HDP cases. A previous review of 16 international HDP guidelines has identified opportunities for improving HDP management in Indonesian primary care, but it has not determined the suitability of the recommendations in practice. This study aims to achieve consensus among the experts regarding the recommendations suitability and to develop HDP pathways in Indonesian primary care.

Methods

Maternal health experts, including GPs, midwives, nurses, medical specialists and health policy researchers from Indonesia and overseas were recruited for the study. They participated in a consensus development process that applied a mix of quantitative and qualitative questions in three Delphi survey rounds. At the first and second-round survey, the participants were asked to rate their agreement on whether each of 125 statements about HDP and HDP management is appropriate for use in Indonesian primary care settings. The third-round survey presented the drafts of HDP pathways and sought participants’ agreement and further suggestions. The participants’ agreement scores were calculated with a statement needing a minimum of 70% agreement to be included in the HDP pathways. The participants’ responses and suggestions to the free text questions were analysed thematically.

Results

A total of 52 participants were included, with 48, 45 and 37 of them completing the first, second and third round of the survey respectively. Consensus was reached for 115 of the 125 statements on HDP definition, screening, management and long-term follow-up. Agreement scores for the statements ranged from 70.8–100.0%, and potential implementation barriers of the pathways were identified. Drafts of HDP management pathways were also agreed upon and received suggestions from the participants.

Conclusions

Most evidence-based management recommendations achieved consensus and were included in the developed HDP management pathways, which can potentially be implemented in Indonesian settings. Further investigations are needed to explore the acceptability and feasibility of the developed HDP pathways in primary care practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03735-3.

Predicting future state for adaptive clinical pathway management

Clinical decision support systems are assisting physicians in providing care to patients. However, in the context of clinical pathway management such systems are rather limited as they only take the current state of the patient into account and ignore the possible evolvement of that state in the future. In the past decade, the availability of big data in the healthcare domain did open a new era for clinical decision support. Machine learning technologies are now widely used in the clinical domain, nevertheless, mostly as a tool for disease prediction. A tool that not only predicts future states, but also enables adaptive clinical pathway management based on these predictions is still in need. This paper introduces weighted state transition logic, a logic to model state changes based on actions planned in clinical pathways. Weighted state transition logic extends linear logic by taking weights - numerical values indicating the quality of an action or an entire clinical pathway - into account. It allows us to predict the future states of a patient and it enables adaptive clinical pathway management based on these predictions. We provide an implementation of weighted state transition logic using semantic web technologies, which makes it easy to integrate semantic data and rules as background knowledge. Executed by a semantic reasoner, it is possible to generate a clinical pathway towards a target state, as well as to detect potential conflicts in the future when multiple pathways are coexisting. The transitions from the current state to the predicted future state are traceable, which builds trust from human users on the generated pathway.

What Are Models of Care? A Systematic Search and Narrative Review to Guide Development of Care Models for Premature Ovarian Insufficiency

No specific model of care (MoC) is recommended for premature ovarian insufficiency (POI), despite awareness that POI is associated with comorbidities requiring multidisciplinary care. This article aims to explore the definitions and central components of MoC in health settings, so that care models for POI can be developed. A systematic search was performed on Ovid Medline and Embase, and including gray literature. Unique definitions of MoC were identified, and thematic analysis was used to summarize the key component of MoC. Of 2,477 articles identified, 8 provided unique definitions of MoC, and 11 described components of MoC. Definitions differ in scope, focusing on disease, service, or system level, but a key feature is that MoC is operational, describing how care is delivered, as well as what that care is. Thematic analysis identified 42 components of MoC, summarized into 6 themes-stakeholder engagement, supporting integrated care, evidence-based care, defined outcomes and evaluation, behavior change methodology, and adaptability. Stakeholder engagement was central to all other themes. MoCs operationalize how best practice care can be delivered at a disease, service, or systems level. Specific MoC should be developed for POI, to improve clinical and process outcomes, translate evidence into practice, and use resources more efficiently.

Unpacking Healthcare Professionals' Work to Achieve Coherence in the Healthcare Journey of Elderly Patients: An Interview Study

Aim

Today, seamless, person-centered healthcare is emphasized when dealing with elderly patients with comprehensive needs. Studies have uncovered a complex healthcare terrain. Despite a great deal of effort on the part of policy makers and healthcare providers, the work healthcare professionals undertake to develop seamless healthcare is still unclear. Therefore, the aim of this study was to uncover the work that healthcare professionals undertake to achieve coherent and comprehensive healthcare for elderly patients with multiple health problems during their journey through the complex healthcare terrain.

Methods

This study has an explorative design with individual interviews. Twenty-five healthcare professionals from primary and specialist care agreed to participate. A thematic analysis method was employed.

Results

The analyses revealed three central themes in the healthcare professionals’ work to build coherence in the patients’ care trajectory: Working to manage a patient’s illness trajectory during the course of the patient’s life, working to achieve a comprehensive overall picture, and considering multiple options in a “patchwork” terrain.

Conclusion

Healthcare professionals have a common understanding that hospital stays are a short part of the elderly person’s journey in the healthcare system. In the comprehensive work to obtain the overall picture of the illness trajectory within the patient’s life story, healthcare professionals emphasized the importance of working in an interdisciplinary manner. Interprofessional consulting and collaboration should be strengthened to build coherence in the older patient’s complex care trajectory.

Patient Inventory: a quality improvement method

Providing high quality care requires that patient care pathways are organized according to the needs of the patient. The organization of high-quality integrated patient care requires methods to assess 'appropriateness' of the care pathways to identify challenges in delivering the right procedure, for the right person at the right time and setting and with the most appropriate use of resources. There is a need for methods to assess appropriateness that can easily be implemented in daily clinical practice. The Patient Inventory method is such a method. Patient Inventory is a special type of audit that provides a 'snapshot' of the patient population in an entire hospital, a ward or another clinical unit. It maps the bed occupancy situation, as well as coordination, continuity and communication associated with the individual patient pathway. The aim is to identify inappropriate or wasteful events and to facilitate reflections on the underlying causes. These reflections are used to identify focus areas for quality improvement efforts. The method answers the question: 'Is it the right patient in the right place at the right time, and is the correct pathway for the patient organized with the most appropriate use of resources?' The aim of this method paper is to describe the background, definitions and methodologies for Patient Inventory, to offer a practical guidance for application of the method and to describe the current experiences with the method.

RarERN Path: a methodology towards the optimisation of patients' care pathways in rare and complex diseases developed within the European Reference Networks

BACKGROUND

In 2017, the European Commission has launched the European Reference Networks (ERNs), virtual networks involving healthcare providers across Europe. The aim of the ERNs is to tackle complex and rare diseases and conditions that require highly specialized treatment and a concentration of knowledge and resources. The ERN on rare and complex connective tissue and musculoskeletal diseases (ERN ReCONNET) is one of the 24 ERNs approved that aims to improve the management of Rare and Complex Connective Tissue and Musculoskeletal Diseases.

OBJECTIVE

The RarERN Path methodology aims to create a single reference organisational model for patients' care pathways which, if applied in different contexts, helps to ensure an improved, cost-effective and patient-centred equal care to rare and complex diseases.

METHODS

Starting from existing standard methods for the creation and elaboration of patients' care pathways, a specific methodology was created in order to take advantage of the distinctive and peculiar characteristics of the ERNs. Specifically, the development of the RarERN Path methodology involved different stakeholders: health economists, clinicians and researchers expert in rare and complex diseases, communication experts, experts in patients' involvement and narrative medicine and policy-makers.

RESULTS

The RarERN Path methodology foresees six consecutive phases, each with different and specific aims. Specifically, the six phases are represented by: Phase 1-mapping of existing patients' care pathways and patients' stories; Phase 2-design of an optimised common patients' care pathway; Phase 3-consensus on an optimised common patients' care pathway; Phase 4-key performance indicators definition; Phase 5-refinement; Phase 6-pilot phase (optional).

CONCLUSION

The application of RarERN Path to the different disease-specific and geographical contexts would help to ensure an improved, cost-effective and patient-centred equal care to rare and complex diseases across Europe as well as a possible tangible action towards the integration of ERNs into the different European healthcare systems.

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.

Perinatal Resilience for the First 1,000 Days of Life. Concept Analysis and Delphi Survey

Background

The ability to cope with challenges and stress in life is generally understood as resilience. Pregnancy and parenthood are challenging times. The concept of resilience is receiving increasing interest from researchers, clinicians, and policy staff because of its potential impact on health, well-being, and quality of life. Nevertheless, the concept is less studied during the perinatal period.

Objectives

The aim of this study is to understand the concept of perinatal resilience, including the underlying processes and more specifically for the first 1,000 days of life.

Methods

A concept analysis according to the Walker and Avant (2011) framework was used, to investigate the basic elements of the concept. Concurrently, a two-round Delphi survey involving researchers, clinicians, epidemiologists, mothers, and fathers (N = 21), was conducted to prioritize the terms associated with perinatal resilience. Data collection took place between January and April 2019.

Results

Through concept analysis and Delphi survey, five defining attributes for perinatal resilience were identified: social support, self-efficacy, self-esteem, sense of mastery and personality. The additional terms, rated important by the Delphi survey, were linked to the consequences of being resilient during the perinatal period for the individual and his/her family. Specifically, highlighted were the experiences of families in personal growth and achieving family balance, adaptation, or acceptance.

Conclusion

Based on the results of the concept analysis and Delphi survey, we describe perinatal resilience for the first 1,000 days as a circular process towards a greater well-being in the form of personal growth, family balance, adaptation or acceptance, when faced with stressors, challenges or adversity during the perinatal period. The presence of resiliency attributes such as social support, sense of mastery, self-efficacy, and self-esteem enhance the capacity to be resilient and probably prevent mental health problems.

Effects of oncological care pathways in primary and secondary care on patient, professional and health systems outcomes: a systematic review and meta-analysis

BACKGROUND

Pathways are frequently used to improve care for cancer patients. However, there is little evidence about the effects of pathways used in oncological care. Therefore, we performed a systematic review and meta-analysis aiming to identify and synthesize existing literature on the effects of pathways in oncological care.

METHODS

All patients diagnosed with cancer in primary and secondary/tertiary care whose treatment can be characterized as the strategy "care pathways" are included in this review. A systematic search in seven databases was conducted to gather evidence. Studies were screened by two independent reviewers. Study outcomes regarding patients, professionals, and system level were extracted from each study.

RESULTS

Out of 13,847 search results, we selected 158 articles eligible for full text assessment. One hundred fifty studies were excluded and the remaining eight studies represented 4786 patients. Most studies were conducted in secondary/tertiary care. Length of stay (LOS) was the most common used indicator, and was reported in five studies. Meta-analysis based on subgroups showed an overall shorter LOS regarding gastric cancer (weighted mean difference (WMD)): - 2.75, CI: - 4.67 to - 0.83) and gynecological cancer (WMD: - 1.58, CI: - 2.10 to - 1.05). Costs were reported in six studies and most studies reported lower costs for pathway groups.

CONCLUSIONS

Despite the differences between the included studies, we were able to present an evidence base for cancer care pathways performed in secondary/tertiary care regarding the positive effects of LOS in favor of cancer care pathways.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017057592.

Optimal Care Pathways for People with Lung Cancer- a Scoping Review of the Literature

INTRODUCTION

Much of the existing work around implementation of cancer optimal care pathways (OCP) has either focused exclusively on the clinical elements of care or has targeted individual stages in the cancer trajectory, rather than using a patient-centred or service delivery lens to inform the integration of care across the continuum. This review aimed to identify and summarise the available literature on lung cancer OCP.

METHODS

A scoping review was conducted, with literature across multiple databases and grey literature searched. Articles were included if the OCP was being used to manage adult patients with lung cancer and reported on either the development process and outcomes and/or barriers and facilitators associated with optimal care pathway development and/or uptake.

RESULTS

Of the 381 references screened, 32 articles were included. The lung cancer pathways reviewed varied significantly. A number of themes were identified including the development and implementation of the OCP; the use of quality indicators to audit the OCP; and studies on outcomes of the OCP incorporating timeliness of care delivery, patient experiences and health care utilisation and costs.

CONCLUSIONS

The limited number of relevant articles found in this review may suggest that an OCP for lung cancer is still in its preliminary stages across the broader health systems.

Data-Driven Personalization of a Physiotherapy Care Pathway: Case Study of Posture Scanning

Background

Advanced sensor, measurement, and analytics technologies are enabling entirely new ways to deliver health care. The increased availability of digital data can be used for data-driven personalization of care. Data-driven personalization can complement expert-driven personalization by providing support for decision making or even by automating some parts of decision making in relation to the care process.

Objective

The aim of this study was to analyze how digital data acquired from posture scanning can enhance physiotherapy services and enable more personalized delivery of physiotherapy.

Methods

A case study was conducted with a company that designed a posture scan recording system (PSRS), which is an information system that can digitally record, measure, and report human movement for use in physiotherapy. Data were collected through interviews with different stakeholders, such as health care professionals, health care users, and the information system provider, and were analyzed thematically.

Results

Based on the results of our thematic analysis, we propose three different types of support that posture scanning data can provide to enhance and enable more personalized delivery of physiotherapy: 1) modeling the condition, in which the posture scanning data are used to detect and understand the health care user’s condition and the root cause of the possible pain; 2) visualization for shared understanding, in which the posture scanning data are used to provide information to the health care user and involve them in more collaborative decision-making regarding their care; and 3) evaluating the impact of the intervention, in which the posture scanning data are used to evaluate the care progress and impact of the intervention.

Conclusions

The adoption of digital tools in physiotherapy has remained low. Physiotherapy has also lacked digital tools and means to inform and involve the health care user in their care in a person-centered manner. In this study, we gathered insights from different stakeholders to provide understanding of how the availability of digital posture scanning data can enhance and enable personalized physiotherapy services.

Implementation of an easy in-hospital educational stoma pathway results in decrease of home nursing care services after discharge

AIM

New stoma patients often rely heavily on the assistance of the ward nursing staff during the hospital stay and on the availability of home nursing care services (HNCS) after discharge. An easily executable 4-day in-hospital educational stoma pathway was developed and implemented. The aim was to increase their level of independence (LOI) in order to reduce the need for HNCS after discharge.

METHOD

All new stoma patients on the gastrointestinal surgery ward, physically and psychologically capable of performing independent stoma care (SC), were enrolled in this pathway. They were compared to a retrospective control group of new stoma patients before the onset of the stoma pathway. The primary outcome is the need and frequency of HNCS for SC at the moment of discharge. Secondary outcome is the LOI in SC at discharge.

RESULTS

A total of 145 patients [m:f = 102:43, median age 67 (range 27-90) years] were included in the present study. Patients requiring daily HNCS for SC decreased from 80% to 50%, P < 0.001; patients discharged without HNCS for SC increased from 5% to 27%. Patients' independence in SC at discharge increased from 8% to 68%, P < 0.001.

CONCLUSION

This study shows that a clinical 4-day in-hospital educational stoma pathway is feasible and effective in increasing the LOI in SC of new stoma patients and significantly reducing their need for HNCS. Cost-benefit analysis and applicability of this pathway in multicentre settings are currently being investigated.

Exploring integrated supply chain performance in healthcare: a service provider perspective

Purpose

The paper identifies the antecedents and consequences of integrated supply chain performance (ISCP) in healthcare systems.

Design/methodology/approach

Based on a review of the literature constructs of supply chain flexibility (SCF), employee relationships (ERs), organizational orientation (OO) and knowledge exchange (KE) were identified as antecedents of ISCP, and patient centricity (PC) emerged as its consequence. This structural relationship was tested using partial least square structural equation modeling (PLS-SEM).

Findings

ERs, SCF, OO and KE positively impacted the performance of an integrated healthcare supply chain. Furthermore, enhanced ISCP in operational processes of the hospital positively influenced patient centeredness and care quality.

Research limitations/implications

Paper contributes by identifying antecedents and consequences of ISCP. Future researchers may explore the inter-relationships among the antecedents of ISCP.

Practical implications

Insights from this study will help practitioners in enhancing hospital operations by integrating processes along the healthcare service supply chain and developing a patient-centric approach.

Social implications

This paper highlights how PC may be achieved by focusing on a facilitative internal environment. This understanding may help in designing processes that deliver health as a social good in an effective manner.

Originality/value

The empirical evidence from this study can help hospitals integrate their functions, thus, enabling them to deliver quality care.