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Plishka CT, Rotter T, Penz ED, Hansia MR, Fraser SKA, Marciniuk DD. Effects of Clinical Pathways for COPD on Patient, Professional, and Systems Outcomes: A Systematic Review. Chest 2019; 156:864-877. [PMID: 31150639 DOI: 10.1016/j.chest.2019.04.131] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 04/18/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND COPD has a substantial burden seen in both patient quality of life and health-care costs. One method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs bring the best available evidence to a range of health-care professionals by adapting guidelines to a local context and detailing essential steps in care. METHODS A systematic review was conducted to address the following question: What are the effects of CPWs for COPD on patient-, professional-, and systems-level outcomes? The review used methods outlined by the Cochrane Collaboration. We included all studies that met our operational definition for CPWs and focused on COPD. All studies were evaluated for risk of bias, and all data regarding patient, professional, and systems outcomes were extracted. RESULTS The search strategy identified 497 potentially relevant titles. Of these, 13 studies were included in the review. These studies reported a total of 398 outcomes, with sufficient data for meta-analysis of five outcomes: complications, length of stay, mortality, readmissions, and quality of life. Results showed statistically significant reductions in complications, readmissions, and length of stay but did not show changes in mortality or quality of life. CONCLUSIONS This systematic review reveals evidence to suggest that CPWs for COPD have the potential to reduce complications, readmissions, and length of stay without negatively influencing mortality or quality of life. However, quality of evidence was generally low. The authors therefore acknowledge that results should be interpreted with caution and note the need for additional research in this area.
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Affiliation(s)
- Christopher T Plishka
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Thomas Rotter
- Health Quality Programs, School of Nursing, Queen's University, Kingston, ON, Canada
| | - Erika D Penz
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, Respiratory Research Center, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Shana-Kay A Fraser
- British Virgin Islands Health Services Authority, Road Town, Tortola, British Virgin Islands
| | - Darcy D Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, Respiratory Research Center, University of Saskatchewan, Saskatoon, SK, Canada
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Shi M, Wang J, Zhang L, Yan Y, Miao YD, Zhang X. Effects of Integrated Case Payment on Medical Expenditure and Readmission of Inpatients with Chronic Obstructive Pulmonary Disease: A Nonrandomized, Comparative Study in Xi County, China. Curr Med Sci 2018; 38:558-566. [PMID: 30074226 DOI: 10.1007/s11596-018-1914-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/07/2017] [Indexed: 01/05/2023]
Abstract
In the past few decades, Chinese government attempted to reduce the economic burden of chronic diseases and lower family financial risk of patients by establishing a nationwide coverage of Social Health Insurance system. However, the payment mode of Social Health Insurance varies across Chinese healthcare settings, and the effectiveness of each mode differs. This study aimed to evaluate the effects of integrated case payment on medical expenditure and readmission of inpatients with chronic obstructive pulmonary disease (COPD), a complex, multicomponent, chronic condition. A nonrandomized, comparative method was used in this study. Inpatients with COPD before (n=1569) and after the integrated case payment reform (n=4764) were selected from the inpatient information database of the New Cooperative Medical Scheme Agency of Xi County. The integrated case payment comprises the case payment (including price-cap case payment and fixed-reimbursement case payment) and clinical pathway (including clinical pathway A, clinical pathway B and clinical pathway C). Effects of integrated case payment were evaluated with indicators of per capita total medical expense and readmission within 30 days. A multivariate linear regression and a binary logistic regression were used to conduct statistical analysis. The results showed that case payment, comprising price-cap case payment β=2382.988, P<0.001) and fixed-reimbursement case payment β=2613.564, P<0.001), and clinical pathway C β=1996.467, P<0.001) were risk factors of per capita total medical expenses. Clinical pathway A β=1443.409, P<0.001) and clinical pathway B β=1583.791, P<0.001) were protective factors. The interactive effects of case payment with hospital level β=0.710, P<0.001) lowered the readmission rate within 30 days. Meanwhile, clinical pathways A β=18.949, P<0.001), B (β=19.152, PO.OOl) and C β=1.882, P<0.001) were associated with the rate increase. The findings revealed that integrated case payment ensured the quality of care for inpatients with COPD to some extent. However, this payment mode increased the per capita total medical expense. Further, policy-makers should set reasonable reimbursement standards of case payment, unify the type of case payment, and strengthen the supervision of the reform to enhance its function on medical cost control.
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Affiliation(s)
- Meng Shi
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Jing Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yan Yan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Yu-Dong Miao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, 211166, China
| | - Xiang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China. .,Research Center for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China.
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Vanhaecht K, Sermeus W, Peers J, Lodewijckx C, Deneckere S, Leigheb F, Decramer M, Panella M. The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial. Trials 2010; 11:111. [PMID: 21092098 PMCID: PMC3001422 DOI: 10.1186/1745-6215-11-111] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 11/19/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospital treatment of chronic obstructive pulmonary disease (COPD) frequently does not follow published evidences. This lack of adherence can contribute to the high morbidity, mortality and readmissions rates. The European Quality of Care Pathway (EQCP) study on acute exacerbations of COPD (NTC00962468) is undertaken to determine how care pathways (CP) as complex intervention for hospital treatment of COPD affects care variability, adherence to evidence based key interventions and clinical outcomes. METHODS An international cluster Randomized Controlled Trial (cRCT) will be performed in Belgium, Italy, Ireland and Portugal. Based on the power analysis, a sample of 40 hospital teams and 398 patients will be included in the study. In the control arm of the study, usual care will be provided. The experimental teams will implement a CP as complex intervention which will include three active components: a formative evaluation of the quality and organization of care, a set of evidence based key interventions, and support on the development and implementation of the CP. The main outcome will be six-month readmission rate. As a secondary endpoint a set of clinical outcome and performance indicators (including care process evaluation and team functioning indicators) will be measured in both groups. DISCUSSION The EQCP study is the first international cRCT on care pathways. The design of the EQCP project is both a research study and a quality improvement project and will include a realistic evaluation framework including process analysis to further understand why and when CP can really work. TRIAL REGISTRATION NUMBER NCT00962468.
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Affiliation(s)
- Kris Vanhaecht
- European Pathway Association, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Faculty of Medicine, Catholic University Leuven, Belgium
| | - Walter Sermeus
- European Pathway Association, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Faculty of Medicine, Catholic University Leuven, Belgium
| | - Jan Peers
- Faculty of Medicine, Catholic University Leuven, Belgium
| | | | - Svin Deneckere
- Faculty of Medicine, Catholic University Leuven, Belgium
| | - Fabrizio Leigheb
- Faculty of Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
| | - Marc Decramer
- Faculty of Medicine, Catholic University Leuven, Belgium
| | - Massimiliano Panella
- European Pathway Association, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
- Faculty of Medicine, Amedeo Avogadro University of Eastern Piedmont, Italy
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Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010:CD006632. [PMID: 20238347 DOI: 10.1002/14651858.cd006632.pub2] [Citation(s) in RCA: 294] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.
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Affiliation(s)
- Thomas Rotter
- Department of Public Health, Dresden Medical School, University of Dresden, Dresden, Germany, D-01307
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