1
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Wenk J, Voigt I, Inojosa H, Schlieter H, Ziemssen T. Building digital patient pathways for the management and treatment of multiple sclerosis. Front Immunol 2024; 15:1356436. [PMID: 38433832 PMCID: PMC10906094 DOI: 10.3389/fimmu.2024.1356436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
- Judith Wenk
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Isabel Voigt
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hernan Inojosa
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hannes Schlieter
- Research Group Digital Health, Faculty of Business and Economics, Technische Universität Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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2
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Geheran B, Kumar S, Ma’u E. Care pathways in forensic mental health services in New Zealand. PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2022; 30:553-564. [PMID: 37484510 PMCID: PMC10360999 DOI: 10.1080/13218719.2022.2059030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
On entering forensic mental health services (FMHS) patients progress along forensic care pathways (FCP) that aim to maximise well-being and reduce risk of reoffending. They progress through high-, medium-, and low-secure psychiatric units with changing care and security needs. There is minimal literature examining FCP or their efficacy. This retrospective study describes the characteristics of patients admitted to an acute FMHS and explores the clinical, sociodemographic, and legal factors that influence FCP progression. Most patients were referred from prison (65.1%) and presented with violent index offending (62.4%) and psychotic disorder (80.6%). Young Maori men with psychosis predominated the forensic population. Logistic regression revealed violent index offending and diagnosis were determinants of following FCP, while violent offending and longer duration of stay were predictive of FCP progression. This study found no reduction in re-hospitalisation rates or inpatient length of stay over a three year follow-up for patients that completed the FCP.
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Affiliation(s)
- B. Geheran
- Psychiatry, Auckland District Health Board, Auckland, New Zealand
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
| | - S. Kumar
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
- Psychiatry, The University of Auckland Waikato Clinical School, Hamilton, New Zealand
| | - E. Ma’u
- Forensic MHS, Waikato District Health Board, Hamilton, New Zealand
- Psychiatry, The University of Auckland Waikato Clinical School, Hamilton, New Zealand
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3
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Bauer J, Kösel E, Henkel AG, Spinner CD, Kolisch R. [Integrated care concepts and multidisciplinary process chains in a radiological context]. Radiologe 2022; 62:331-342. [PMID: 35201396 DOI: 10.1007/s00117-022-00976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
Modern patient-centered and cost-efficient care concepts in hospitals require the mapping of multidisciplinary process chains into clinical pathways. Clinical decision support systems and operations research methods use algorithms to classify patients into homogeneous groups and to model a complete clinical pathway for scheduling individual procedures. An improvement of the economic situation of the care facility can be achieved through improved resource utilization, reduced patient waiting times and a shortening of the length of stay. The interdisciplinary use of centrally stored interoperable information and comprehensive care management via information technology (IT) services lay the foundation for the dissolution of traditional IT system architectures in medicine and the development of flexibly integrable modern system platforms. New IT approaches such as the semantically standardized definition of procedures and resource properties, the use of clinical decision support systems and the use of service-oriented system architectures form the basis for the deep integration of radiology services into comprehensive interdisciplinary care concepts.
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Affiliation(s)
- J Bauer
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - E Kösel
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A G Henkel
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - C D Spinner
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - R Kolisch
- Lehrstuhl für Operations Management, Fakultät für Wirtschaftswissenschaften, Technische Universität München, München, Deutschland
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4
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Soejima H, Matsumoto K, Nakashima N, Nohara Y, Yamashita T, Machida J, Nakaguma H. A functional learning health system in Japan: Experience with processes and information infrastructure toward continuous health improvement. Learn Health Syst 2021; 5:e10252. [PMID: 34667875 PMCID: PMC8512723 DOI: 10.1002/lrh2.10252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/03/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction and definition of the term Learning Health System (LHS) appears to have occurred initially around 2007. Prior to this and the introduction of electronic health records (EHR), a predecessor could be found in the Clinical Pathways concept as a standard medical care plan and a tool to improve medical quality. Since 1997, Japan's Saiseikai Kumamoto Hospital (SKH) has been studying and implementing Clinical Pathways. In 2010, they implemented EHR, which facilitated the collection of structured data in common templates that aligned with outcome measurements defined through Japan's Society of Clinical Pathways. For each patient at this hospital, variances from the desired outcomes have been recorded, producing volumes of structured data in formats that could readily be aggregated and analyzed. A visualization tool was introduced to display graphs on the home page of the EHR such that each patient can be compared to similar patients. Knowledge learned from patient care is shared regularly through Clinical Pathways meetings that are supported by all staff within the hospital. The SKH experience over the past two decades is worth exploring further in the context of the development of a fully functional LHS and the attributes/characteristics thereof. In this report, the SKH experience and processes are compared with previously published attributes of a fully functional LHS (ie, characteristics of an LHS that can indicate maturity). Specific examples of the SKH system are detailed with respect to leveraging knowledge gained to change performance that improves patient care as prescribed by learning health cycles. The SKH experience and its information infrastructure and culture exemplify a functional LHS, which is now being expanded to additional hospitals with the hope that it can be scaled and serve as a solid platform for measures aimed at improving medical care, thus establishing broader and more global learning health systems.
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Affiliation(s)
| | | | | | - Yasunobu Nohara
- Faculty of Advanced Science and TechnologyKumamoto UniversityKumamotoJapan
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5
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Mériade L, Rochette C. Integrated care pathway for breast cancer: A relational and geographical approach. Soc Sci Med 2020; 270:113658. [PMID: 33421916 DOI: 10.1016/j.socscimed.2020.113658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
This paper examines how to apply a spatial approach (relational and geographical) to care pathways for their better integration within their territories. Based on the case study of a senology department of a French Cancer Diagnosis, Treatment and Research Centre, we apply a mixed research methodology using qualitative data (synthesis documents, meeting minutes, in-depth interviews) and quantitative data relating to the mobility and geographical location of a cohort of 1798 patients treated in this centre. Our results show the inseparable nature of the relational dimension and the geographical approach to move towards greater integration of breast cancer care pathways. This inseparability is constructed from the proposal of a method for mapping the integrated care pathways in their territories. This method, applied to our case study, allows us to identify four main categories of pathways for the cohort of patients studied.
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Affiliation(s)
- Laurent Mériade
- CleRMa - Research Chair "Health and Territories" - IAE School of Management - Clermont Auvergne University, 11, boulevard Charles de Gaulle, 63000, Clermont-Ferrand, France.
| | - Corinne Rochette
- CleRMa - Research Chair "Health and Territories" - IAE School of Management - Clermont Auvergne University, 11, boulevard Charles de Gaulle, 63000, Clermont-Ferrand, France.
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6
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Latina R, Salomone K, D’Angelo D, Coclite D, Castellini G, Gianola S, Fauci A, Napoletano A, Iacorossi L, Iannone P. Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228634. [PMID: 33233824 PMCID: PMC7699889 DOI: 10.3390/ijerph17228634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Roberto Latina
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Katia Salomone
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Daniela D’Angelo
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Daniela Coclite
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Alice Fauci
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Antonello Napoletano
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Laura Iacorossi
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
- Correspondence:
| | - Primiano Iannone
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
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7
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de Figueiredo RP, Filho JBF, Sousa FRC, Weber P, Litchfield I. Automated Verification of Care Pathways Using Constraint Programming. IEEE J Biomed Health Inform 2020; 24:2718-2725. [PMID: 32142461 DOI: 10.1109/jbhi.2020.2977032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Bad construction of modeled care pathways can lead to satisfiability problems during the pathway execution. These problems can ultimately result in medical errors and need to be checked as formally as possible. Therefore, this study proposes a set of algorithms using a free open-source library dedicated to constraint programming allied with a DSL to encode and verify care pathways, checking four possible problems: states in deadlock, non-determinism, inaccessible steps and transitions with logically equivalent guard conditions. We then test our algorithms in 84 real care pathways used both in hospitals and surgeries. Using our algorithms, we were able to find 200 problems taking less than 1 second to complete the verification on most pathways.
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8
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Vanhaecht K, de Witte K, Sermeus W. The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/205343450701100202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.
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Affiliation(s)
- Kris Vanhaecht
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
| | - Karel de Witte
- Belgian Dutch Clinical Pathway Network, Leuven
- Center for Organisation and Personnel Psychology, Catholic University Leuven, Leuven, Belgium
| | - Walter Sermeus
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
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9
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Gervasi G, Bellomo G, Mayer F, Zaccaria V, Bacigalupo I, Lacorte E, Canevelli M, Corbo M, Di Fiandra T, Vanacore N. Integrated care pathways on dementia in Italy: a survey testing the compliance with a national guidance. Neurol Sci 2019; 41:917-924. [PMID: 31836948 PMCID: PMC7160089 DOI: 10.1007/s10072-019-04184-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/29/2019] [Indexed: 11/05/2022]
Abstract
Dementias are chronic, degenerative neurological disorders with a complex management that require the cooperation of different healthcare professionals. The Italian Ministry of Health produced the document “Guidance on Integrated Care pathway for People with Dementia” (GICPD) with the specific objective of providing a standardized framework for the definition, development, and implementation of integrated care pathways (ICP) dedicated to people with dementia. We searched all available Italian territorial ICPs. Two raters assessed the retrieved ICPs with a 2-point scale on a 43-item checklist based on the GICPD. Only 5 out of 21 regions and 5 out of 101 local health authorities had an ICP, with most ICPs having a moderate compliance to the GICPD, in particular for the items referring to the development and implementation of the care pathways. A low to moderate inter-rater agreement was observed, mainly due to a lack of standardized models to describe ICPs for dementias. Results suggest that policy- and decision-makers should pay more attention to the GICPD when producing ICPs. The direct communication with clinicians, and the implementation of more precise and appropriate clinical outcomes, could increase the involvement of clinicians, whose participation is crucial to guarantee that ICPs meet needs of patients and their carers.
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Affiliation(s)
- Giuseppe Gervasi
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.,Department of Biomedicine and Prevention, Hygiene and Preventive Medicine School, University of Rome Tor Vergata, Rome, Italy
| | - Guido Bellomo
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Flavia Mayer
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Valerio Zaccaria
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Ilaria Bacigalupo
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Eleonora Lacorte
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Marco Canevelli
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.,Department of Human Neuroscience "Sapienza", University of Rome, Rome, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa Cura Policlinico, Via Dezza 48, 20144, Milan, Italy
| | - Teresa Di Fiandra
- General Directorate for Health Prevention, Ministry of Health, Rome, Italy
| | - Nicola Vanacore
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.
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10
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Sather EW, Iversen VC, Svindseth MF, Crawford P, Vasset F. Patients' perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalization and the community. J Eval Clin Pract 2019; 25:1131-1141. [PMID: 31144419 DOI: 10.1111/jep.13206] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/12/2019] [Accepted: 05/18/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Patients with mental health problems experience numerous transitions into and out of hospital. This study explores former patients' views of pathways in transition between district psychiatric hospital centres (DPCs) and community mental health services. METHOD A descriptive qualitative design was chosen. Three focus group interviews with a total of 10 informants from five different communities were conducted. Interviews were transcribed and analysed thematically where themes describe promoting or inhibitory factors to the transition phase. RESULTS The informants shared their experiences on issues promoting and preventing successful care pathways in mental health. Four main paired themes were identified: (a) patient participation/activation/empowerment versus paternalism and institutionalization, (b) patient-centred care versus care interpreted as humiliation, (c) interprofessional collaboration or teamwork versus unsafe patient pathways in mental health services, and (d) sustainable integrated care versus fragmented, noncollaborative care. CONCLUSIONS Shared decision making was reported more precisely as informed shared decision making. Shared information between all parties involved in care pathways is key.
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Affiliation(s)
- Eva W Sather
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Valentina C Iversen
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Mental Health, St Olav's University Hospital HF, Tiller District Psychiatric Centre, Trondheim, Norway
| | - Marit F Svindseth
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Aalesund, Norway
| | - Paul Crawford
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Froydis Vasset
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Aalesund, Norway
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11
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Ricciardi C, Fiorillo A, Valente AS, Borrelli A, Verdoliva C, Triassi M, Improta G. Lean Six Sigma approach to reduce LOS through a diagnostic-therapeutic-assistance path at A.O.R.N. A. Cardarelli. TQM JOURNAL 2019. [DOI: 10.1108/tqm-02-2019-0065] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The rise of the mean age incremented the occurrence of femur fractures with respect to the past, leading thus to serious consequences, as regards morbidity and socio-economic impact. The direction of the A.O.R.N. Cardarelli of Naples has introduced a DTAP whose aim was the reduction of LOS. The paper aims to discuss this issue.
Design/methodology/approach
The aim of this paper is to analyze the introduction of DTAP, employing Lean Thinking and Six Sigma methodology based on the DMAIC cycle. To evaluate the effectiveness of DTAP, two groups of patients have been observed for 14 months (before and after the implementation of DTAP).
Findings
Statistical tests were performed on the groups and graphics were provided to visualize the decrease of LOS (29.9 per cent). The overall population was also divided in subgroups according to six variables potentially influencing LOS.
Research limitations/implications
Authors considered six variables of influences; yet, others could be taken into account in the future.
Practical implications
The decrease of costs due to the management of elderly patients with femur fracture, the optimization of care processes in hospitals and a faster recovery for patients is the tangible contribute of DTAP.
Originality/value
The implementation of DTAP allowed the hospital to obtain a significant reduction of LOS with a consequently decrease of costs alleviating the hospital and the society from the socio-economic burden and the morbidity of this pathology.
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12
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Szelągowski M, Berniak-Woźny J. A Process-Centered Approach to the Description of Clinical Pathways-Forms and Determinants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152638. [PMID: 31344806 PMCID: PMC6695712 DOI: 10.3390/ijerph16152638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/17/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
The aim of the study is to indicate the need for variability in the presentation of clinical pathways, in various phases of their implementation, and to define the forms of presentation of clinical pathways required by physicians in both the Hospital Information Systems (HIS) and Electronic Medical Records (EMR) Systems, as well as the determinants of the selection of the forms of description, in relation to the performed medical actions. The results of the study are a significant lead-in towards further research on the required form of the user interface in systems supporting dynamic business process management (dynamic BPM). The research is a pilot of a survey study, conducted to ascertain the usefulness and feasibility of the adopted methodology, for a wider project on the determinants of the form of description of clinical pathways. An exploratory pilot survey, in a large multi-specialization hospital in Poland, was conducted. The survey sample consisted of 28 purposely selected heads of all hospital departments, and the medical team of the pediatric ward. Descriptive analysis was carried out on the data collected. The results of the study have unambiguously supported the claim that physicians require the form of presentation of clinical pathways to change, depending on the particular phase of the diagnostic–therapeutic process, as well as establishing the main determinants thereof. This pilot study is one of the first attempts to establish the factors determining the choice of clinical pathway presentation in HIS/EMR systems. While not conclusively decisive in terms of the forms of presentation or the determinants of their choice, it indicates the directions of further research, both from the point of view of ergonomics and the usability of HIS/EMR systems, as well as the management of medical knowledge, as part of the dynamic management of clinical pathways.
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Affiliation(s)
- Marek Szelągowski
- Systems Research Institute, Polish Academy of Sciences, 00-001 Warsaw, Poland
| | - Justyna Berniak-Woźny
- Faculty of Business and International Relations, Vistula University, 02-787 Warsaw, Poland.
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13
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McKeown A, Cliffe C, Arora A, Griffin A. Ethical challenges of integration across primary and secondary care: a qualitative and normative analysis. BMC Med Ethics 2019; 20:42. [PMID: 31269930 PMCID: PMC6610833 DOI: 10.1186/s12910-019-0386-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/26/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention. METHODS We evaluated an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners (GPs) in co-designing integrated clinical services. RESULTS The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based. CONCLUSIONS From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making.
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Affiliation(s)
- Alex McKeown
- Department of Psychiatry, University of Oxford, Warneford Lane, Oxford, OX3 7JX, England
| | - Charlotte Cliffe
- University College London Medical School, 74 Huntley Street, London, WC1E 6AU, England
| | - Arun Arora
- University of Manchester Medical School, Oxford Road, Manchester, M13 9PL, UK
| | - Ann Griffin
- Research Department for Medical Education, University College London Medical School, 74 Huntley Street, London, WC1E 6AU, England.
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Lawal AK, Groot G, Goodridge D, Scott S, Kinsman L. Development of a program theory for clinical pathways in hospitals: protocol for a realist review. Syst Rev 2019; 8:136. [PMID: 31176372 PMCID: PMC6556023 DOI: 10.1186/s13643-019-1046-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/13/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the increased utilization of clinical pathways (CPWs) as a strategy to improve patient and system outcomes in hospitals, there remain ongoing challenges with their conceptualization, implementation, and evaluation. Theories that explain how CPWs work in hospitals are lacking, making it difficult to identify important factors for sustaining changes arising from CPWs implemented in hospitals. The objective of this realist review is to develop a program theory for CPWs in hospitals. METHODS This is a protocol for a realist review. The review will use a six-step iterative process to develop a program theory for CPWs in hospitals: (1) development of a preliminary program theory; (2) search strategy and literature search; (3) study selection and appraisal; (4) data extraction; (5) data analysis and synthesis; and (6) stakeholder engagement. In addition to searching the gray literature and contacting authors, we will search electronic databases such as MEDLINE, NHSEED, CINAHL EBSCO, HMIC, and PsycINFO. Studies will be included based on their ability to provide data that test some aspect of the program theory. Two independent reviewers will select, screen, and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome heuristics that explains how CPWs implemented in hospitals translates to better health system outcomes. DISCUSSION Overall, the review aims to develop a program theory for CPWs in hospitals and to explore how, why, to what extent, and in what contexts does the implementation of CPWs in hospitals contribute to better health system outcomes. As a result, the review will provide a theoretical framework of how CPWs work in hospitals. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018103220.
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Affiliation(s)
- Adegboyega K Lawal
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada.
| | - Gary Groot
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Donna Goodridge
- Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Shannon Scott
- Faculty of Nursing, University of Alberta Edmonton, Edmonton, Canada
| | - Leigh Kinsman
- University of Newcastle and Mid-North Coast Local Health District, Port Macquarie Base Hospital, Port Macquarie, Australia
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Vassbotn AD, Sjøvik H, Tjerbo T, Frich J, Spehar I. General practitioners' perspectives on care coordination in primary health care: A qualitative study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2018; 21:153-159. [PMID: 30595842 PMCID: PMC6297895 DOI: 10.1177/2053434518816792] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction To explore Norwegian general practitioners' experiences with care coordination in primary health care. Methods Qualitative study using data from five focus groups with 32 general practitioners in Norway. We analysed the data using systematic text condensation, a descriptive and explorative method for thematic cross-case analysis of qualitative data. Results The general practitioners had different notions of care pathways. They expressed a wish and an obligation to be involved in planning and coordination of primary health-care services, but they experienced organisational and financial barriers that limited their involvement and contribution. General practitioners reported lack of information about and few opportunities for involvement in formal coordination initiatives, and they missed informal arenas for dialogue with other primary health-care professionals. They argued that the general practitioner's role as coordinator should be recognised by other parties and that they needed financial compensation for contributions and attendance in meetings with the municipality. Discussion General practitioners need informal arenas for dialogue with other primary health-care professionals and access to relevant information to promote coordinated care. There might be an untapped potential for improving patient care involving general practitioners more in planning and coordinating services at the system level. Financial compensation of general practitioners contribution may promote increased involvement by general practitioners.
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Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
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Vanhaecht K, Bollmann M, Bower K, Gallagher C, Gardini A, Guezo J, jansen U, Massoud R, Moody K, Sermeus W, Van Zelm R, Whittle C, Yazbeck AM, Zander K, Panella M. Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/205343540601000106] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To give an overview on the use and prevalence of clinical pathways. Design Cross-sectional descriptive study. Study participants European Pathway Association (E-P-A) contact persons in 23 countries. Results Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care. Conclusions There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.
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Affiliation(s)
- Kris Vanhaecht
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Marcus Bollmann
- SANA Kliniken, Munich, Germany
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Kathy Bower
- Centre for Case Management, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Clare Gallagher
- Patient Concern & Healthcare Events, London, England, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Andrea Gardini
- International Society for Quality in Healthcare, Ancona, Italy
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Jen Guezo
- Board of Health, Castel, Guernsey
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Uwe jansen
- KISS Project & General practitioners part, County of Sønderjylland, Denmark
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Rashad Massoud
- Institute for Healthcare Improvement, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Karen Moody
- Integrated Care Pathway User Group, Glasgow, Scotland, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Walter Sermeus
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Ruben Van Zelm
- Institute for Healthcare Improvement CBO, Utrecht, The Netherlands
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Claire Whittle
- School of Health Sciences, Birmingham University, Birmingham, England, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Anne-Marie Yazbeck
- Ministry of Health, Department for Quality, Ljubljana, Slovenia
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Karen Zander
- Centre for Case Management, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Massimiliano Panella
- University of Eastern Piedmont ‘Amedeo Avogadro’, Novara, Italy
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
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Sather EW, Svindseth MF, Crawford P, Iversen VC. Care pathways in the transition of patients between district psychiatric hospital centres (DPCs) and community mental health services. Health Sci Rep 2018; 1:e37. [PMID: 30623072 PMCID: PMC6266453 DOI: 10.1002/hsr2.37] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/28/2018] [Accepted: 03/13/2018] [Indexed: 11/06/2022] Open
Abstract
RATIONALE AIMS AND OBJECTIVES Patients with mental health problems experience numerous transitions into and out of hospital. Primary care providers have mixed success in identifying and managing patients' needs. This study explores health personnel's experience of care pathways in patient transition between inpatient and community mental health services. METHODS A descriptive qualitative design was chosen. Four focus group interviews with 12 informants from 7 different communities were conducted. Interviews were analyzed thematically. RESULTS Two main themes were identified: integrated care and patient activation. The participants shared their experiences on topics that can affect smooth care pathways in mental health. Six promoting factors were identified for successful patient transition: opportunities for information sharing, implementation of systematic plans, use of e-messages, around-the-clock care, designating one responsible health person in each system for each patient, and the involvement of patients and their families. The following barriers were all found to impede the patients' transition between levels of care: the lack of a single responsible person at each health care level, insufficient meetings, the absence of systematic plans, difficulties in identifying the right staff at different levels, delays in information sharing, and the complexity of welfare systems negatively affecting patient dignity. CONCLUSIONS Systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. A single person should take charge of ensuring sufficient connection and communication between inpatient and community mental health services. Finally, both patient and staff in community services should be linked through a direct telephone number with around-the-clock availability.
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Affiliation(s)
- Eva W. Sather
- Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
| | - Marit F. Svindseth
- Faculty of Medicine and Health ScienceNorwegian University of Science and TechnologyAalesundNorway
| | - Paul Crawford
- Faculty of Medicine and Health SciencesUniversity of NottinghamUK
| | - Valentina C. Iversen
- Faculty of Medicine and Health Sciences, Department of Mental HealthNorwegian University of Science and Technology, St Olav's University Hospital HF, Tiller District Psychiatric CentreTrondheimNorway
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Asmirajanti M, Syuhaimie Hamid AY, Hariyati TS. Clinical care pathway strenghens interprofessional collaboration and quality of health service: a literature review. ENFERMERIA CLINICA 2018. [DOI: 10.1016/s1130-8621(18)30076-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Introduction There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact. Methods Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake. Results Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators. Conclusions Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.
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Abstract
PURPOSE In an attempt to avoid future revisionist history, the author offers a 30-year retrospective (1986-2016) on the evolution of strategies to reduce length of stay (LOS). She and her colleagues have been involved from the onset by developing tools such as critical paths, roles such as clinical case management, and operational systems for managing measureable outcome-driven care from the bedside to the boardroom. PRIMARY PRACTICE SETTING Acute care hospitals. FINDINGS/CONCLUSIONS The LOS for all inpatients has changed dramatically from 1970 (average LOS = 7.8 days) through solidly between 2005 and 2012 (average LOS = 4.5 days in 2012) despite a significant increase in the average age of hospital inpatients (; ). For patients 65 years and older, who comprised 38% of all inpatients, the decrease has been more drastic: from 12.6 days in 1970 to 5.5 days in 2005-2010 ().With the exception of hospitalists and case management staff, acute care hospitals have essentially doubled productivity without adding additional direct care full-time equivalents! Described in terms of "low-hanging" to "high-hanging" fruit, this article outlines the classic methods used to reduce LOS and concludes with some implications of LOS for health care reform. The U.S. health system could not have accomplished this feat without case managers and social workers. IMPLICATIONS FOR CASE MANAGEMENT Acute care services should be very proud of their achievements and use their reputation to empower their work for the next frontier, which will be reducing cost per case, especially in risk contracts. Everything old seems new again.
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Affiliation(s)
- Karen Zander
- Karen Zander, MS, RN, CMAC, FAAN, is President and CEO of The Center for Case Management. Her pioneering work with clinical case management and CareMap systems, begun at New England Medical Center Hospitals in Boston 30 years ago, is internationally recognized. Karen has authored many articles and recent texts including (1) Competency Evaluation Tools for Case Management Professionals, (2) Emergency Department Case Management: The Compendium of Best Practices 2nd edition with K. Walsh, and Hospital Case Management Models: Evidence Connecting the Bedside to the Boardroom. She holds a BSN from Illinois Wesleyan University (IWU), an MS in Psychiatric-Mental Health Nursing from Boston University, postgraduate credits from MIT, and an honorary Doctorate in Humane Letters (DHL) from IWU. She teaches at Northeastern University in Boston and also plays the cello in a community orchestra
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Abstract
PURPOSE The purpose of this paper is to systematically apply theory of organisational routines to standardised care pathways. The explanatory power of routines is used to address open questions in the care pathway literature about their coordinating and organising role, the way they change and can be replicated, the way they are influenced by the organisation and the way they influence health care professionals. DESIGN/METHODOLOGY/APPROACH Theory of routines is systematically applied to care pathways in order to develop theoretically derived propositions. FINDINGS Care pathways mirror routines by being recurrent, collective and embedded and specific to an organisation. In particular, care pathways resemble standard operating procedures that can give rise to recurrent collective action patterns. In all, 11 propositions related to five categories are proposed by building on these insights: care pathways and coordination, change, replication, the organisation and health care professionals. Research limitations/implications - The paper is conceptual and uses care pathways as illustrative instances of hospital routines. The propositions provide a starting point for empirical research. PRACTICAL IMPLICATIONS The analysis highlights implications that health care professionals and managers have to consider in relation to coordination, change, replication, the way the organisation influences care pathways and the way care pathways influence health care professionals. Originality/value - Theory on organisational routines offers fundamental, yet unexplored, insights into hospital processes, including in particular care coordination.
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Affiliation(s)
- Thim Prætorius
- Department of Business and Management, Aalborg University Copenhagen, Copenhagen, Denmark and Centre of Health Economics Research, Department of Business and Economics, University of Southern Denmark, Odense, Denmark
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Ortoleva Bucher C, Dubuc N, von Gunten A, Trottier L, Morin D. Development and validation of clinical profiles of patients hospitalized due to behavioral and psychological symptoms of dementia. BMC Psychiatry 2016; 16:261. [PMID: 27450155 PMCID: PMC4957848 DOI: 10.1186/s12888-016-0966-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 07/12/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patients hospitalized on acute psychogeriatric wards are a heterogeneous population. Cluster analysis is a useful statistical method for partitioning a sample of patients into well separated groups of patients who present common characteristics. Several patient profile studies exist, but they are not adapted to acutely hospitalized psychogeriatric patients with cognitive impairment. The present study aims to partition patients hospitalized due to behavioral and psychological symptoms of dementia into profiles based on a global evaluation of mental health using cluster analysis. METHODS Using nine of the 13 items from the Health of the Nation Outcome Scales for elderly people (HoNOS65+), data were collected from a sample of 542 inpatients with dementia who were hospitalized between 2011 and 2014 in acute psychogeriatric wards of a Swiss university hospital. An optimal clustering solution was generated to represent various profiles, by using a mixed approach combining hierarchical and non-hierarchical (k-means) cluster analyses associated with a split-sample cross-validation. The quality of the clustering solution was evaluated based on a cross-validation, on a k-means method with 100 random initial seeds, on validation indexes, and on clinical interpretation. RESULTS The final solution consisted of four clinically distinct and homogeneous profiles labeled (1) BPSD-affective, (2) BPSD-functional, (3) BPSD-somatic and (4) BPSD-psychotic according to their predominant clinical features. The four profiles differed in cognitive status, length of hospital stay, and legal admission status. CONCLUSION In the present study, clustering methods allowed us to identify four profiles with distinctive characteristics. This clustering solution may be developed into a classification system that may allow clinicians to differentiate patient needs in order to promptly identify tailored interventions and promote better allocation of available resources.
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Affiliation(s)
- Claudia Ortoleva Bucher
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, Route de la Corniche 10, 1010, Lausanne, Switzerland.
| | - Nicole Dubuc
- Research Centre on Aging, Sherbrooke University Geriatrics Institute, Quebec, Canada ,School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
| | - Armin von Gunten
- Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Lise Trottier
- Research Centre on Aging, Sherbrooke University Geriatrics Institute, Quebec, Canada
| | - Diane Morin
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, Route de la Corniche 10, 1010 Lausanne, Switzerland ,Faculty of Nursing Sciences, Laval University, Quebec, Canada
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Improving the performance of surgery-based clinical pathways: a simulation-optimization approach. Health Care Manag Sci 2016; 20:1-15. [PMID: 27270957 DOI: 10.1007/s10729-016-9371-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
Abstract
This paper aims to improve the performance of clinical processes using clinical pathways (CPs). The specific goal of this research is to develop a decision support tool, based on a simulation-optimization approach, which identify the proper adjustment and alignment of resources to achieve better performance for both the patients and the health-care facility. When multiple perspectives are present in a decision problem, critical issues arise and often require the balancing of goals. In our approach, meeting patients' clinical needs in a timely manner, and to avoid worsening of clinical conditions, we assess the level of appropriate resources. The simulation-optimization model seeks and evaluates alternative resource configurations aimed at balancing the two main objectives-meeting patient needs and optimal utilization of beds and operating rooms.Using primary data collected at a Department of Surgery of a public hospital located in Genoa, Italy. The simulation-optimization modelling approach in this study has been applied to evaluate the thyroid surgical treatment together with the other surgery-based CPs. The low rate of bed utilization and the long elective waiting lists of the specialty under study indicates that the wards were oversized while the operating room capacity was the bottleneck of the system. The model enables hospital managers determine which objective has to be given priority, as well as the corresponding opportunity costs.
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Bonnabel L, Huteau MÈ, Filhol N, Clottes E, Massin J, Quenet F, Stoebner-Delbarre A. [Combining clinical pathway and patient education approaches]. REVUE DE L'INFIRMIÈRE 2016:38-40. [PMID: 26743372 DOI: 10.1016/j.revinf.2015.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The integration of the therapeutic education of the patient into a clinical pathway approach helps to optimise nursing practice. Despite some limits, this method allows the position of the caregiver to evolve, going beyond the required methodological framework. It results in the emergence of several new educational facets which are essential for the patient and enable them to become a player in their own care.
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Affiliation(s)
- Laurence Bonnabel
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Marie-Ève Huteau
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Nathalie Filhol
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Edwige Clottes
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Julie Massin
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - François Quenet
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France
| | - Anne Stoebner-Delbarre
- Utep Pôle soins de support, Institut régional du Cancer de Montpellier, Parc Euromédecine, Avenue des Apothicaires, 34298 Montpellier cedex 5, France.
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Kurth E, Krähenbühl K, Eicher M, Rodmann S, Fölmli L, Conzelmann C, Zemp E. Safe start at home: what parents of newborns need after early discharge from hospital - a focus group study. BMC Health Serv Res 2016; 16:82. [PMID: 26955832 PMCID: PMC4782306 DOI: 10.1186/s12913-016-1300-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background The length of postpartum hospital stay is decreasing internationally. Earlier hospital discharge of mothers and newborns decreases postnatal care or transfers it to the outpatient setting. This study aimed to investigate the experiences of new parents and examine their views on care following early hospital discharge. Methods Six focus group discussions with new parents (n = 24) were conducted. A stratified sampling scheme of German and Turkish-speaking groups was employed. A ‘playful design’ method was used to facilitate participants communication wherein they used blocks and figurines to visualize their perspectives on care models The visualized constructions of care models were photographed and discussions were audio-recorded and transcribed verbatim. Text and visual data was thematically analyzed by a multi-professional group and findings were validated by the focus group participants. Results Following discharge, mothers reported feeling physically strained during recuperating from birth and initiating breastfeeding. The combined requirements of infant and self-care needs resulted in a significant need for practical and medical support. Families reported challenges in accessing postnatal care services and lacking inter-professional coordination. The visualized models of ideal care comprised access to a package of postnatal care including monitoring, treating and caring for the health of the mother and newborn. This included home visits from qualified midwives, access to a 24-h helpline, and domestic support for household tasks. Participants suggested that improving inter-professional networks, implementing supervisors or a centralized coordinating center could help to remedy the current fragmented care. Conclusions After hospital discharge, new parents need practical support, monitoring and care. Such support is important for the health and wellbeing of the mother and child. Integrated care services including professional home visits and a 24-hour help line may help meet the needs of new families. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1300-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elisabeth Kurth
- Institute of Midwifery, Zurich University of Applied Sciences, Winterthur, Switzerland. .,Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Midwifery-Network, Familystart beider Basel, Basel, Switzerland.
| | - Katrin Krähenbühl
- Health Division, Bern University of Applied Sciences, Bern, Switzerland.
| | - Manuela Eicher
- School of Health Sciences Fribourg, University of Applied Arts and Sciences Western Switzerland, Fribourg, Switzerland. .,Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland.
| | - Susanne Rodmann
- Midwifery-Network, Familystart beider Basel, Basel, Switzerland. .,Department of Obstetrics and Gynecology, University Hospital, Basel, Switzerland.
| | - Luzia Fölmli
- Parents Counselling Basel-Stadt, Basel, Switzerland.
| | | | - Elisabeth Zemp
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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Song XP, Tian JH, Cui Q, Zhang TT, Yang KH, Ding GW. Could clinical pathways improve the quality of care in patients with gastrointestinal cancer? A meta-analysis. Asian Pac J Cancer Prev 2015; 15:8361-6. [PMID: 25339029 DOI: 10.7314/apjcp.2014.15.19.8361] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This meta-analysis was performed to assess the implementation effects of clinical pathways in patients with gastrointestinal cancer. A comprehensive search was conducted in the Cochrane Library, PubMed, EMBASE, Web of Science and Chinese Biomedical Literature Database (from inception to May 2014). Selection of studies, assessing risk of bias and extracting data were performed by two reviewers independently. Outcomes were analyzed by fixed-effects and random-effects model meta-analysis and reported as mean difference (MD), standardized mean difference (SMD) and odds ratio (OR) with 95% confidence intervals (CI). The Jadad methodological approach was used to assess the quality of included studies and the meta-analysis was conducted with RevMan 5.1 software. Nine citations (eight trials) involving 642 patients were included. The aggregate results showed that a shorter average length of stay [MD = -4.0; 95% CI (-5.1, -2.8); P < 0.00001] was observed with the clinical pathways as compared with the usual care. A reduction in inpatient expenditure [SMD = -1.5; 95% CI (-2.3, -0.7); P = 0.0001] was also associated with clinical pathways, along with higher patient satisfaction [OR = 4.9; 95% CI (2.2, 10.6); P < 0.0001]. Clinical pathways could improve the quality of care in patients with gastrointestinal cancer, as evidenced by a significant reduction in average length of stay, a decrease in inpatient expenditure and an improvement in patient satisfaction. Therefore, indicators and mechanisms within clinical pathways should be a focus in the future.
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Affiliation(s)
- Xu-Ping Song
- School of Public Health, Lanzhou University, Lanzhou, China E-mail :
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Mammen C, Matsell DG, Lemley KV. The importance of clinical pathways and protocols in pediatric nephrology. Pediatr Nephrol 2014; 29:1903-14. [PMID: 23955786 DOI: 10.1007/s00467-013-2577-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/28/2013] [Accepted: 07/10/2013] [Indexed: 11/25/2022]
Abstract
Modern clinical practice is increasingly delivered by teams of individuals working within an environment of rising complexity and daunting patient care loads. Clinical pathways, protocols and checklists offer a way to assure coordination, efficiency, quality and safety in this chaotic environment. In this review, we discuss some of the principal characteristics of these clinical tools, some of the challenges involved with introducing them into clinical practice and the evidence that they can positively affect patient and system outcomes. We believe pediatric nephrology, as a discipline, is ready for the widespread introduction of these important quality tools.
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Affiliation(s)
- Cherry Mammen
- Division of Nephrology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada,
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Devapriam J, Alexander R, Gumber R, Pither J, Gangadharan S. Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2014; 18:211-220. [PMID: 24814150 DOI: 10.1177/1744629514532453] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Specialist intellectual disability inpatient units have come under increased scrutiny, leading to questions about the quality of service provision in this sector. A care pathway-based approach was implemented in such a unit and its impact on outcome variables was measured. The care pathway-based approach resulted in the turnover of more patients, increased capacity for admissions to the unit, reduced lengths of stay in hospital, timely assessments and treatments, which resulted in better outcomes in patients. Care pathway-based approach to service provision provides not only better outcomes in patients but also a reliable way of ensuring true multi-agency working and accountability. If used widely, it can reduce the variability in the quality of current service provision.
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Zhang M, Zhou SY, Xing MY, Xu J, Shi XX, Zheng SS. The application of clinical pathways in laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2014; 13:348-53. [PMID: 25100118 DOI: 10.1016/s1499-3872(14)60279-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is one of the most frequent abdominal surgical procedures. The present meta-analysis aimed to estimate the clinical effects of implementing a clinical pathway for LC compared with standard medical care by evaluating the length of hospital stay, costs, and the outcomes of patients undergoing LC. DATA SOURCES Data were extracted from the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Chinese Medical Citation Index (CMCI), Chinese Medical Current Contents (CMCC), and China BioMedical Literature Database (CBM). We also searched the reference lists of the relevant articles and conference articles. Only randomized controlled trials and controlled clinical trials published from 1980 to 2013 were included. We did not set restrictions on language and country of publications. All of the data were evaluated and analyzed by two reviewers independently with RevMan software (version 5.0). RESULTS A total of 7 trials with 1187 patients were included. The patients who underwent LC with clinical pathway had shorter hospital stay [weighted mean difference=-1.90, 95% CI: -2.65 to -1.16, P<0.00001], lower cost [standard mean difference=-0.69, 95% CI: -0.82 to -0.56, P<0.00001], and better questionnaires based satisfaction with the medical services. CONCLUSIONS The applications of the clinical pathway for LC effectively reduced hospital stay and total costs. However, there was insufficient evidence for proving the differences in postoperative complications. Future research should focus on patient outcomes and identify the mechanisms underlying the effect of the clinical pathway.
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Affiliation(s)
- Min Zhang
- Department of General Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Wood S, Gangadharan S, Tyrer F, Gumber R, Devapriam J, Hiremath A, Bhaumik S. Successes and Challenges in the Implementation of Care Pathways in an Intellectual Disability Service: Health Professionals' Experiences. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2014. [DOI: 10.1111/jppi.12063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Susan Wood
- Leicestershire Partnership NHS Trust; Leicester UK
| | | | - Freya Tyrer
- Leicestershire Partnership NHS Trust; Leicester UK
- Department of Health Sciences; University of Leicester; Leicester UK
| | - Rohit Gumber
- Leicestershire Partnership NHS Trust; Leicester UK
| | | | | | - Sabyasachi Bhaumik
- Leicestershire Partnership NHS Trust; Leicester UK
- Department of Health Sciences; University of Leicester; Leicester UK
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The QUIRO Study (assurance of quality and innovation in radiooncology): methodology, instruments and practices. Strahlenther Onkol 2014; 190:138-48. [PMID: 24408057 DOI: 10.1007/s00066-013-0555-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/11/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The QUIRO study aimed to establish a secure level of quality and innovation in radiation oncology. Over 6 years, 27 specific surveys were conducted at 24 radiooncological departments. In all, 36 renowned experts from the field of radiation oncology (mostly head physicians and full professors) supported the realization of the study. METHODS A salient feature of the chosen methodological approach is the "process" as a means of systematizing diversified medical-technical procedures according to standardized criteria. On the one hand, "processes" as a tool of translation are adapted for creating and transforming standards into concrete clinical and medical actions; on the other hand, they provide the basis for standardized instruments and methods to determine the required needs of physicians, staff, and equipment. In the foreground of the collection and measurement of resource requirements were the processes of direct service provision which were subdivided into modules for reasons of clarity and comprehensibility. Overhead tasks (i.e., participation in quality management) were excluded from the main study and examined in a separate survey with appropriate methods. RESULTS After the exploration of guidelines, tumor- or indication-specific examination and treatment processes were developed in expert workshops. Moreover, those specific modules were defined which characterize these entities and indications in a special degree. Afterwards, these modules were compiled according to their time and resources required in the "reference institution", i.e., in specialized and as competent recognized departments (mostly from the university area), by various suitable survey methods. CONCLUSION The significance of the QUIRO study and the validity of the results were optimized in a process of constant improvements and comprehensive checks. As a consequence, the QUIRO study yields representative results concerning the resource requirement for specialized, qualitatively and technologically highly sophisticated radiooncologic treatment in Germany.
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Thurston J, Waterworth S. ‘Making sense’: nurses' experiences of changing practice in caring for dying patients in New Zealand. Int J Palliat Nurs 2012; 18:500-7. [DOI: 10.12968/ijpn.2012.18.10.500] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jenny Thurston
- Auckland City Hospital, Private Bag 92-024, Auckland, 1023, New Zealand
| | - Susan Waterworth
- School of Nursing, The University of Auckland, Private Bag 92019, Auckland, New Zealand
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Kul S, Barbieri A, Milan E, Montag I, Vanhaecht K, Panella M. Effects of care pathways on the in-hospital treatment of heart failure: a systematic review. BMC Cardiovasc Disord 2012; 12:81. [PMID: 23009030 PMCID: PMC3507726 DOI: 10.1186/1471-2261-12-81] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 09/19/2012] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care. METHODS Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case-control studies, cohort studies and time interrupted series. RESULTS Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials. CONCLUSION By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.
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Affiliation(s)
- Seval Kul
- Department of Biostatistics, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Antonella Barbieri
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont 'A. Avogadro', Novara, Italy
| | | | - Ilke Montag
- Center for Health Services and Nursing Research, School of Public Health, Catholic University, Leuven, Belgium
| | - Kris Vanhaecht
- Center for Health Services and Nursing Research, School of Public Health, Catholic University, Leuven, Belgium
- European Pathway Association, Leuven, Belgium
| | - Massimiliano Panella
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont 'A. Avogadro', Novara, Italy
- European Pathway Association, Leuven, Belgium
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Sarrechia M, Van Gerven E, Hermans L, Deneckere S, Sermeus W, Panella M, Spitz B, Vanhaecht K. Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety? J Adv Nurs 2012; 69:278-85. [PMID: 22489652 DOI: 10.1111/j.1365-2648.2012.06004.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To report a study to determine whether or not variations exist in evidence-based key interventions in pathway documents for normal delivery across hospitals. BACKGROUND Care pathways are used worldwide to standardize and follow up patient-focused care. Minimal variations in pathway documents increase standardization and patient safety. DESIGN A descriptive study design using qualitative methods was used, to examine the various key interventions present in care pathway documents for normal delivery. METHODS Between January-March 2009, we evaluated the content of the care pathway document for normal delivery from 17 different hospitals. The key interventions in these pathways were compared with the 40 evidence-based key interventions of Map of Medicine®. RESULTS There was much variation in the characteristics and the presence of key interventions in the pathway documents. Only 6 of the 40 evidence-based key interventions (15%) were found in all 17 pathway documents and 20 of the 40 interventions (50%) were found in only 10 pathway documents. CONCLUSION If variation already exists among the care pathway documents, this may lead to a high probability of variation in the actual performance of daily care. In this study is shown that, even for highly predictable medical conditions, there are huge differences in the evidence-based content and structure of pathways. Lack of evidence base could potentially endanger both patient safety and the health professional.
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Abstract
AIMS To discuss the intricacies of the decision-making process about initiating end-of-life care pathways. BACKGROUND Internationally, enhancing the quality of end-of-life care has become a central concern in governments' health policies. Despite limited empirical evaluation, end-of- life care pathways have been championed and widely adopted as complex interventions to enhance end-of-life care worldwide. DATA SOURCES A literature search of established electronic databases was conducted for published articles in English addressing decision-making and end-of-life care pathways between 1997-2010. Manual searches of relevant journals and internet sites were also undertaken. DISCUSSION The initiation of an end-of-life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision-making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end-of- life care. Accordingly, nurses need not only an appreciation of end-of-life care pathways, but the complexities surrounding the decision to commence a pathway and their role within. CONCLUSION The initiation of an end-of-life care pathway is contingent on the outcome of a complex decision-making process which is rarely explored and poorly understood.
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Affiliation(s)
- Tessa Watts
- Department of Nursing, College of Human and Health Sciences, Swansea University, Swansea, UK.
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Yamazaki T, Umemoto K. Knowledge Management of Healthcare by Clinical-Pathways. JOURNAL OF INFORMATION & KNOWLEDGE MANAGEMENT 2011. [DOI: 10.1142/s0219649210002577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Healthcare is a knowledge-intensive service provided by professionals, such as medical doctors, nurses, and pharmacists. Clinical-pathways are used by many healthcare organisations (HCOs) as a tool for performing the healthcare process, sharing and utilising knowledge from different professionals. In this paper, case studies were performed at two HCOs that use clinical-pathways actively in the healthcare process. Theoretical model construction, sharing, utilisation, and creation of the knowledge by different professionals, were tested by the case study of two HCOs which use clinical pathways actively. The theoretical model was a knowledge creation model which creates new knowledge continuously. In this theoretical model, clinical-pathways are suggested to be an effective tool for knowledge management in healthcare.
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Affiliation(s)
- Tomoyoshi Yamazaki
- School of Knowledge Science, Japan Advanced Institute of Science and Technology, Ishikawa Prefecture, Japan
| | - Katsuhiro Umemoto
- School of Knowledge Science, Japan Advanced Institute of Science and Technology, Ishikawa Prefecture, Japan
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Watts T. End-of-life care pathways as tools to promote and support a good death: a critical commentary. Eur J Cancer Care (Engl) 2011; 21:20-30. [PMID: 22066609 DOI: 10.1111/j.1365-2354.2011.01301.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This paper calls into question whether and how end-of-life care pathways facilitate the accomplishment of a 'good death'. Achieving a 'good death' is a prominent social and political priority and an ideal which underpins the philosophy of hospice and palliative care. End-of-life care pathways have been devised to enhance the care of imminently dying patients and their families across care settings and thereby facilitate the accomplishment of a 'good death'. These pathways have been enthusiastically adopted and are now recommended by governments in the UK as 'best practice' templates for end-of-life care. However, the literature reveals that the 'good death' is a nebulous, fluid concept. Moreover, concerns have been articulated regarding the efficacy of care pathways in terms of their impact on patient care and close analysis of two prominent end-of-life pathways reveals how biomedical aspects of care are privileged. Nonetheless drawing on a diverse range of evidence the literature indicates that end-of-life care pathways may facilitate a certain type of 'good death' and one which is associated with the dying process and framed within biomedicine.
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Affiliation(s)
- T Watts
- Department of Nursing, College of Human and Health Sciences, Swansea University, Swansea, UK.
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Andreae C, Ekstedt M, Snellman I. Patients' participation as it appears in the nursing documentation, when care is ruled by standardized care plans. ISRN NURSING 2011; 2011:707601. [PMID: 22007324 PMCID: PMC3169373 DOI: 10.5402/2011/707601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 05/20/2011] [Indexed: 11/23/2022]
Abstract
This study aimed to describe inpatients with myocardial infarction and their participation in care as documented in the nursing records when standardized care plans are used in care. The use of standardized care plans not only has increased the quality of medical treatment but has also overlooked patients' opportunities to participate in their own care. There is a lack of knowledge about how standardized care plans influence patients' participation in nursing care. Data were collected from thirteen patients' records with diagnoses of myocardial infarction. Participation in the decision-making process and participation associated with “sharing with others” were searched for in the analysis. The analytical process was guided by content analysis. The findings were grouped into two categories: patients' intermediary participation and patients' active participation. The main results indicated that patients' intermediary participation depended on healthcare professionals' power to rule the nursing care situation.
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Vanhaecht K, Ovretveit J, Elliott MJ, Sermeus W, Ellershaw J, Panella M. Have We Drawn the Wrong Conclusions About the Value of Care Pathways? Is a Cochrane Review Appropriate? Eval Health Prof 2011; 35:28-42. [DOI: 10.1177/0163278711408293] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kris Vanhaecht
- School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
| | - John Ovretveit
- Medical Management Center, Karolinska Institute, Stockholm, Sweden
| | - Martin J. Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Walter Sermeus
- School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
| | - John Ellershaw
- Marie Currie Palliative Care Center, University of Liverpool, Liverpool, UK
| | - Massimiliano Panella
- School of Public Health, Faculty of Medicine, University of Eastern Piedmont, Novarra, Italy
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Healthcare professionals' experiences of the implementation of integrated care pathways. Int J Health Care Qual Assur 2011; 24:334-47. [DOI: 10.1108/09526861111139179] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Deneckere S, Robyns N, Vanhaecht K, Euwema M, Panella M, Lodewijckx C, Leigheb F, Sermeus W. Indicators for Follow-Up of Multidisciplinary Teamwork in Care Processes. Eval Health Prof 2010; 34:258-77. [DOI: 10.1177/0163278710393736] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In order to study the impact of interventions on multidisciplinary teamwork in care processes, relevant indicators need to be defined. In the present study, the authors performed a Delphi survey of a purposively selected expert panel consisting of scientific researchers and hospital managers. Thirty-six experts from 13 countries participated. Each participant rated a list of team indicators on a scale of 1–6. Consensus was sought in two consecutive rounds. The content validity index (CVI) varied from 8% to 92%. A final list of 19 indicators was generated: 5 on team context/structure, 8 on team process, and 6 on team outcomes. Most relevant team indicators were as follows: “team relations,” “quality of team leadership,” “culture/climate for teamwork,” “team perceived coordination of the care process,” and “team vision.” Scientific researchers and hospital managers that want to study and improve multidisciplinary teamwork in care processes should primarily focus on these team indicators.
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Affiliation(s)
- Svin Deneckere
- Faculty of Medicine, Catholic University Leuven, Belgium
| | | | - Kris Vanhaecht
- Faculty of Medicine, Catholic University Leuven, Belgium
- European Pathway Association, Catholic University of Leuven, Belgium
| | - Martin Euwema
- Center for Organization and Personnel Psychology, Catholic University Leuven, Belgium
| | - Massimiliano Panella
- European Pathway Association, Catholic University of Leuven, Belgium
- Faculty of Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
| | | | - Fabrizio Leigheb
- Faculty of Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
| | - Walter Sermeus
- Faculty of Medicine, Catholic University Leuven, Belgium
- European Pathway Association, Catholic University of Leuven, Belgium
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Abstract
Summary The differentiation of roles, tasks and responsibilities in health care has gradually increased because of efforts to decentralize, specialize and professionalize our health-care systems. These development approaches can on the one hand be regarded as successful, although there is also a negativeflipside. Increased differentiation has concurrently fragmented the delivery of health care, which, in turn, can be divided into structural, clinical and cultural fragmentation. Patients are lost as a result of these conditions of fragmentation. This phenomenon can metaphorically be described as a'Patient Bermuda Triangle’. Actions to dissolve the Patient Bermuda Triangles are commonly termed ‘Integrated health care’, a global buzzword that includes integrated care pathway as well as other integrated health-care strategies. Moreover, integrated care is a means to an end: improved patient outcome. To achieve this, it is crucial to have necessary prerequisites in place: both functional and interactional conditions. This procedure seems to be an organic process where the stakeholders go through gradual changes until the optimum level of integration, as well as mutualistic interactions, is established. If these conditions are concealed or impossible to achieve, developmental work should be ended to avoid the evolvement of antagonistic relations between the stakeholders concerned. This state will likely establish a Patient Bermuda Triangle or reinforce an existing one.
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Affiliation(s)
- Bengt Ahgren
- Nordic School of Public Health, Göteborg, Sweden
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van de Klundert J, Gorissen P, Zeemering S. Measuring clinical pathway adherence. J Biomed Inform 2010; 43:861-72. [DOI: 10.1016/j.jbi.2010.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 07/28/2010] [Accepted: 08/02/2010] [Indexed: 11/27/2022]
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Van Gerven E, Vanhaecht K, Deneckere S, Vleugels A, Sermeus W. Management challenges in care pathways: Conclusions of a qualitative study within 57 health-care organizations. ACTA ACUST UNITED AC 2010. [DOI: 10.1258/jicp.2010.010029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Summary The objectives of this paper are to study the aim of care pathways, who has decisional power concerning pathways, the actual follow-up, challenges in cross-boundary development and the support provided by information and communication technology (ICT). The study design included a qualitative study using semi-structured interviews with 88 care pathway coordinators and members of the executive board in 57 health-care organizations enrolled in the Belgian- Dutch Clinical Pathway Network. The study revealed that the most important objectives for introducing care pathways are more standardization and quality of care. In 76% of the interviewed organizations, pathways are discussed in a committee. There is a lack of continuous follow-up when care pathways are implemented. Pathways can facilitate cross-boundary care, but are a challenge because of the fragmentation within primary care. There is a need for more ICT support for care pathways. In conclusion, the executive board members and pathway coordinators state that clearly formulated objectives, a special steering committee, a clear follow-up to keep pathways alive, cross-boundary collaboration and ICT support are among the main challenges for the management of an organization.
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Affiliation(s)
- E Van Gerven
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - K Vanhaecht
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - S Deneckere
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - A Vleugels
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - W Sermeus
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
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Vanhaecht K, Panella M, van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. ACTA ACUST UNITED AC 2010. [DOI: 10.1258/jicp.2010.010019] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Care pathways, also known as clinical pathways, critical pathways or integrated care pathways, are used all over the world. Although they are used internationally, there are still a large number of misunderstandings. The goal of this paper is to provide an overview on the history of pathways and how pathways are actually perceived and defined. Pathways are more than just a document in the patient record. They are a concept for making patient-focused care operational and supporting the modelling of patient groups with different levels of predictability. Pathways are a method within the field of continuous quality improvement and are used in daily practice as a product in the patient record. This paper explains these different issues and provides an extensive list of references that should support pathway facilitators, clinicians, managers and policy-makers in their search for excellence.
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Gill P, McKenna P, O'Neill H, Thompson J, Timmons D. Pillars and pathways: foundations of recovery in Irish forensic mental health care. ACTA ACUST UNITED AC 2010. [DOI: 10.5042/bjfp.2010.0423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Romeyke T, Stummer H. Kosteneffizienz und Qualitätssicherung durch „Klinische Behandlungspfade“? ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s16024-010-0126-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Vanhaecht K, Bellemans J, De Witte K, Diya L, Lesaffre E, Sermeus W. Does the organization of care processes affect outcomes in patients undergoing total joint replacement? J Eval Clin Pract 2010; 16:121-8. [PMID: 20367824 DOI: 10.1111/j.1365-2753.2009.01130.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgeons realize that safe and efficient care processes for total joint replacement requires more than just well-performed operations. Orthopaedic teams are reorganizing care process to improve efficacy and shorten length of stay. Little is known on the impact of organizational changes on patient outcome. This paper studies the relation between the organization of care processes and patient outcomes in hip and knee. Clinical pathways are used as one of the methods to structure the care process. Although evidence is available on the effect of pathways in total joint replacement, their impact with the organization of the care process has not been studied previously. METHODS A cross-sectional multicentre study was performed on 39 care processes and 737 consecutive patients. Regression models were used to analyse the relation between the organization of the care process and risk-adjusted patient outcomes. The use of pathways and the organization of the care process, measured by the Care Process Self Evaluation Tool (CPSET), were measured at organizational level. Length of stay, pain, mobility and elapsed time to discharge were measured at patient level. RESULTS The use of pathways had a positive effect on four out of five subscales and the overall CPSET score. Using pathways decreased length of stay (P = 0.014), pain (P = 0.052) and elapsed time to discharge (P = 0.003). The CPSET subscale communication was related with three risk adjusted outcomes. Multivariate analysis demonstrated a significant effect by three different variables on the length of stay; (1) use of pathways; (2) coordination of care processes; and (3) communication with patients and family. Both the use of pathways and coordination of the care process were determinants for the elapsed time to discharge. A significant interaction effect was found between use of pathways and coordination of the care process. CONCLUSION This large multicentre study revealed the relation between the use of pathways, organization of the care process and patient outcomes. This information is important for both clinicians and managers to understand and further improve the organization of orthopaedic care. LEVEL OF EVIDENCE Level I prognostic study.
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Affiliation(s)
- Kris Vanhaecht
- Center for Health Services and Nursing Research, School of Public Health, Faculty of Medicine, Catholic University Leuven, Kapucijnenvoer 35, 4th Floor, Leuven B-3000, Belgium.
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Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, Sermeus W. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract 2010; 16:39-49. [PMID: 20367814 DOI: 10.1111/j.1365-2753.2008.01111.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
UNLABELLED SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.
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Affiliation(s)
- Pieter Van Herck
- Centre for Health Services and Nursing Research, Catholic University Leuven, Kapucijnenvoer 35 4th floor, 3000 Leuven, Belgium.
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