A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

Visual Modeling Languages in Patient Pathways: Scoping Review

BACKGROUND

Patient pathways (PPs) are presented as a panacea solution to enhance health system functions. It is a complex concept that needs to be described and communicated well. Modeling plays a crucial role in promoting communication, fostering a shared understanding, and streamlining processes. Only a few existing systematic reviews have focused on modeling methods and standardized modeling languages. There remains a gap in consolidated knowledge regarding the use of diverse visual modeling languages.

OBJECTIVE

This scoping review aimed to compile visual modeling languages used to represent PPs, including the justifications and the context in which a modeling language was adopted, adapted, combined, or developed.

METHODS

After initial experimentation with the keywords used to describe the concepts of PPs and visual modeling languages, we developed a search strategy that was further refined and customized to the major databases identified as topically relevant. In addition, we consulted gray literature and conducted hand searches of the referenced articles. Two reviewers independently screened the articles in 2 stages using preset inclusion criteria, and a third reviewer voted on the discordance. Data charting was done using an iteratively developed form in the Covidence software. Descriptive and thematic summaries were presented following rounds of discussion to produce the final report.

RESULTS

Of 1838 articles retrieved after deduplication, 22 satisfied our inclusion criteria. Clinical pathway is the most used phrase to represent the PP concept, and most papers discussed the concept without providing their operational definition. We categorized the visual modeling languages into five categories: (1) general purpose-modeling language (GPML) adopted without major extension or modification, (2) GPML used with formal extension recommendations, (3) combination of 2 or more modeling languages, (4) a developed domain-specific modeling language (DSML), and (5) ontological modeling languages. The justifications for adopting, adapting, combining, and developing visual modeling languages varied accordingly and ranged from versatility, expressiveness, tool support, and extensibility of a language to domain needs, integration, and simplification.

CONCLUSIONS

Various visual modeling languages were used in PP modeling, each with varying levels of abstraction and granularity. The categorization we made could aid in a better understanding of the complex combination of PP and modeling languages. Standardized GPMLs were used with or without any modifications. The rationale to propose any modification to GPMLs evolved as more evidence was presented following requirement analyses to support domain constructs. DSMLs are infrequently used due to their resource-intensive development, often initiated at a project level. The justifications provided and the context where DSMLs were created are paramount. Future studies should assess the merits and demerits of using a visual modeling language to facilitate PP communications among stakeholders and use evaluation frameworks to identify, modify, or develop them, depending on the scope and goal of the modeling need.

Use and impact of clinical pathways across various healthcare settings: A protocol for an umbrella review of global evidence

AIM

The proposed umbrella review aims to assess the use and impact of clinical pathways on professional practice, patient outcomes, length of hospital stay, hospital costs, patient satisfaction, and hospital staff satisfaction through a synthesis of existing systematic reviews and meta-analyses.

METHODS

Following PRIOR guidelines, a systematic search will be conducted in MEDLINE, Epistemonikos, and the Cochrane Library to identify relevant systematic reviews and meta-analyses, from inception till March 2024. Two reviewers will independently screen titles and abstracts, with a third resolving any disagreements. Full-text articles considered potentially relevant will be assessed for eligibility by the same process. The data extraction form will cover information about the review methods, characteristics of the included primary studies, the types of interventions evaluated, and the reported outcomes. This standardized data extraction form will be piloted by the review team on five to ten articles to ensure all relevant information is recorded. The quality of included systematic reviews and meta-analyses will be evaluated using AMSTAR 2. PROSPERO registration number is CRD42024529371.

RESULTS

The study will present a narrative synthesis of the findings, addressing the clinical and methodological heterogeneity and assessing the impact of clinical pathways on various healthcare outcomes.

CONCLUSION AND IMPLICATIONS

This umbrella review will provide evidence-based insights into the effectiveness, challenges, and best practices of clinical pathways, guiding healthcare decision-making and identifying areas for future research. Results will be disseminated widely to inform policy and improve healthcare service delivery.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this paper is a protocol of an umbrella review.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study

STUDY OBJECTIVE

To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs).

METHODS

Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence.

RESULTS

A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86).

CONCLUSION

Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

The direct and indirect effects of length of hospital stay on the costs of inpatients with stroke in Ningxia, China, between 2015 and 2020: A retrospective study using quantile regression and structural equation models

Importance

Length of hospital stay (LOHS) is the main cost-determining factor of hospitalization for stroke patients. However, previous analyses involving LOHS did not consider confounding or indirect factors, or the effects of other factors on LOHS and inpatient costs.

Objective

To investigate the direct and indirect effects of LOHS on the hospitalization costs of inpatients with ischemic and hemorrhagic stroke.

Design setting and participants

This was a population-based, retrospective, and observational study that analyzed data acquired from the Nationwide Inpatient Sample between 2015 and 2020 relating to ischemic and hemorrhagic stroke in Ningxia, China.

Main outcomes and measures

Hospitalizations were identified by the International Classification of Diseases 10th Revision (ICD-10). Inpatient costs were described by the median M (P25, P75). We used a quantile regression model to estimate the linear relationships between a group of independent variables X and the quantile of the explained variable hospitalization cost (Y). A structural equation model (SEM) was then used to investigate the direct and indirect effects of LOHS on inpatient costs.

Results

The study included 129,444 patients with ischemic stroke and 15,525 patients with hemorrhagic stroke. The median LOHS was 10 (8-13) days for ischemic stroke and 15 (10-22) days for hemorrhagic stroke. The median M (P₂₅, P₇₅) of inpatient costs was $1020 (742-1545) for ischemic stroke and 2813 (1576-6191) for hemorrhagic stroke. The total effect of LOHS on inpatient costs was 0.795 in patients with ischemic stroke. The effect of yearof discharge (X4) and CCI (X8) on inpatient costs was dominated by an indirect effect through the LOHS. The indirect effect was -0.071 (84.52% of the total effect value) and 0.034 (69.39% of the total effect value), respectively. The total effect of LOHS on inpatient costs in patients with hemorrhagic stroke was 0.754. The influence of CCI on inpatient costs was dominated by an indirect effect through LOHS; the indirect effect value was -0.028 (77.78% of the total effect value). The payment type, surgery, method of discharge, and hospital level also exerted an impact on inpatient costs by direct and indirect effects through the LOHS.

Conclusions and relevance

Length of hospital stay (LOHS) was identified as the main factor influencing hospitalization costs. However, other social factors were shown to indirectly influence hospitalization costs through the LOHS. Taking effective measures to further reduce hospitalization costs remains an effective way to control hospitalization costs for stroke patients.

Predicting Hospital Length of Stay at Admission Using Global and Country-Specific Competing Risk Analysis of Structural, Patient, and Nutrition-Related Data from nutritionDay 2007-2015

Hospital length of stay (LOS) is an important clinical and economic outcome and knowing its predictors could lead to better planning of resources needed during hospitalization. This analysis sought to identify structure, patient, and nutrition-related predictors of LOS available at the time of admission in the global nutritionDay dataset and to analyze variations by country for countries with n > 750. Data from 2006–2015 (n = 155,524) was utilized for descriptive and multivariable cause-specific Cox proportional hazards competing-risks analyses of total LOS from admission. Time to event analysis on 90,480 complete cases included: discharged (n = 65,509), transferred (n = 11,553), or in-hospital death (n = 3199). The median LOS was 6 days (25th and 75th percentile: 4–12). There is robust evidence that LOS is predicted by patient characteristics such as age, affected organs, and comorbidities in all three outcomes. Having lost weight in the last three months led to a longer time to discharge (Hazard Ratio (HR) 0.89; 99.9% Confidence Interval (CI) 0.85–0.93), shorter time to transfer (HR 1.40; 99.9% CI 1.24–1.57) or death (HR 2.34; 99.9% CI 1.86–2.94). The impact of having a dietician and screening patients at admission varied by country. Despite country variability in outcomes and LOS, the factors that predict LOS at admission are consistent globally.

Post-Heart Transplant Care Pathway's Impact on Reducing Length of Stay

BACKGROUND

Prolonged length of stay (LOS) has undesirable consequences including increased cost, resource consumption, morbidity, and disruptions in hospital flow.

LOCAL PROBLEM

A high-volume heart transplant center in the Pacific Northwest had a mean index hospital LOS of 23 days, with a goal of 10 days according to the institutional heart transplant care pathway.

METHODS

A retrospective, regression analysis was used to identify the factors contributing to LOS of 41 post-heart transplant patients.

INTERVENTIONS

The post-heart transplant care pathway and order set were modified accordingly and reintroduced to the health care team.

RESULTS

Factors contributing to LOS included number of days (1) until the first therapeutic calcineurin inhibitor level, (2) until intravenous diuretics were no longer required, and (3) outside of a therapeutic calcineurin inhibitor range. The interventions reduced the mean LOS by 8 days.

CONCLUSIONS

Increased awareness of LOS, education, and consistent use of care pathways can significantly reduce length of stay.

Distance-based Classification and Regression Trees for the analysis of complex predictors in health and medical research

Predicting patient outcomes based on patient characteristics and care processes is a common task in medical research. Such predictive features are often multifaceted and complex, and are usually simplified into one or more scalar variables to facilitate statistical analysis. This process, while necessary, results in a loss of important clinical detail. While this loss may be prevented by using distance-based predictive methods which better represent complex healthcare features, the statistical literature on such methods is limited, and the range of tools facilitating distance-based analysis is substantially smaller than those of other methods. Consequently, medical researchers must choose to either reduce complex predictive features to scalar variables to facilitate analysis, or instead use a limited number of distance-based predictive methods which may not fulfil the needs of the analysis problem at hand. We address this limitation by developing a Distance-Based extension of Classification and Regression Trees (DB-CART) capable of making distance-based predictions of categorical, ordinal and numeric patient outcomes. We also demonstrate how this extension is compatible with other extensions to CART, including a recently published method for predicting care trajectories in chronic disease. We demonstrate DB-CART by using it to expand upon previously published dose-response analysis of stroke rehabilitation data. Our method identified additional detail not captured by the previously published analysis, reinforcing previous conclusions. We also demonstrate how by combining DB-CART with other extensions to CART, the method is capable of making predictions about complex, multifaceted outcome data based on complex, multifaceted predictive features.

Effects of Clinical Pathways on Cesarean Sections in China: Length of Stay and Direct Hospitalization Cost Based on Meta-Analysis of Randomized Controlled Trials and Controlled Clinical Trials

The cesarean section (CS) on maternal request increased sharply in China, bringing pressure to medical resources and national insurance. We assessed the use of clinical pathways (CPWs) for CS compared with conventional medical care by outcomes of length of stay (LOS) in hospital and direct hospitalization cost (DHC). Four Chinese electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang, CQVIP, and SinoMed, were explored to December 2020 for the full-text papers published in Chinese. Literature that quantitatively assessed the effects of CPW on LOS or DHC were eligible for inclusion. The weighted mean differences (WMDs) were pooled. Twenty-five articles were included in our analysis, with a total sample of 7761 women. These studies were performed from 2004 to 2017 and reported from 2005 to 2018. The synthesized results showed a shorter LOS (in days) (WMD = −1.37, 95% CI: −1.48 to −1.26) and a less DHC (CNY¥) (WMD = −520.46, 95% CI: −554.06 to −503.63) in the CPW group, comparing with that of conventional care. With the need for CS on the rise, the introduction of CPW could effectively reduce LOS and DHC, thereby releasing the medical resources and insurance pressure.

Machine learning in patient flow: a review

This work is a review of the ways in which machine learning has been used in order to plan, improve or aid the problem of moving patients through healthcare services. We decompose the patient flow problem into four subcategories: prediction of demand on a healthcare institution, prediction of the demand and resource required to transfer patients from the emergency department to the hospital, prediction of potential resource required for the treatment and movement of inpatients and prediction of length-of-stay and discharge timing. We argue that there are benefits to both approaches of considering the healthcare institution as a whole as well as the patient by patient case and that ideally a combination of these would be best for improving patient flow through hospitals. We also argue that it is essential for there to be a shared dataset that will allow researchers to benchmark their algorithms on and thereby allow future researchers to build on that which has already been done. We conclude that machine learning for the improvement of patient flow is still a young field with very few papers tailor-making machine learning methods for the problem being considered. Future works should consider the need to transfer algorithms trained on a dataset to multiple hospitals and allowing for dynamic algorithms which will allow real-time decision-making to help clinical staff on the shop floor.

When time matters: a qualitative study on hospital staff's strategies for meeting the target times in cancer patient pathways

Background

Cancer patient pathways (CPPs) were introduced in Norway in 2015. CPPs are time-bound standardised care pathways that describe the organisation of and responsibilities for diagnostics and treatment, as well as communication with the patient and next of kin. The aim is to ensure that cancer patients experience a well-organised, coherent and predictable pathway without any delays in assessment and diagnostics caused by non-medical reasons. Preventing delays in diagnostics by meeting specific target times is central to the successful implementation of CPPs. The aim of this paper is to describe how hospital staff cope with the increased focus on meeting CPP target times and the measures and strategies implemented by hospitals and their staff.

Methods

Data for this paper were collected in a larger study on implementation and experiences with CPPs among hospital staff, general practitioners, and patients in Norway (2017–2020). The study had a qualitative cross-sectional design, and data were collected through interviews. This article is based on semi-structured interviews with hospital staff (N = 60) in five hospitals.

Results

Hospital staff are highly aware of the target times, and try to comply with them, in the interest of both the patients and the hospitals. The implementation of CPPs was not accompanied by the allocation of additional resources; therefore, hospitals could not simply increase capacity to meet the target times. Instead, they had to develop other strategies. Four categories of strategies were identified: (i) introducing new roles and more staff, (ii) reorganising the workflow, (iii) gaming the system and (iv) outsourcing services.

Conclusions

Hospital staff are torn between meeting the target times and a lack of resources and capacity. This is not unusual in the current healthcare context, where staff face organisational reforms and increasing demands on a regular basis. It is important to recognise frontline workers’ efforts towards realising new organisational changes. Therefore, carefully weighing the benefits against the costs and undertaking the necessary planning are important in the design and implementation of future care and treatment pathways for patients.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study)

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

The Effects of Operational and Financial Performance Failure on BI&A-Enabled Search Behaviors: A Theory of Performance-Driven Search

Abstract for Practice and Policy

Phase angle is associated with length of hospital stay, readmissions, mortality, and falls in patients hospitalized in internal-medicine wards: A retrospective cohort study

OBJECTIVES

The aim of this study was to investigate the predictive value of bioimpedance phase angle (PA) on selected clinical outcomes in patients hospitalized in internal-medicine wards.

METHODS

This was a retrospective observational study of 168 patients admitted to the internalmedicine service (52.9% women, 47.1% men), with a mean (± SD) age of 73.9 ± 15.9 y. Anthropometric examination, laboratory tests, and bioelectrical impedance analysis were performed. Bioimpedance-derived PA was the study's parameter. Length of hospital stay, prospective all-cause hospital readmission, mortality, and falls were the clinical endpoints.

RESULTS

Across the four PA quartile groups, age was incrementally higher (P ≤ 0.001). Multivariate linear regression models showed that PA quartile 1 was significantly associated with length of hospital stay (β, SE) in both crude and adjusted models-respectively, β (SE) = 6.199 (1.625), P ≤ 0.001, and β = 2.193 (1.355), P = 0.033. Over a 9-mo follow-up period, the hazard ratios for readmission, in-hospital falls, and mortality were associated with the lowest phase angle (PA quartile 1 versus quartiles 2-4)-respectively, 2.07 (95% confidence interval [CI], 1.28-3.35), 2.36 (95% CI, 1.05-5.33), and 2.85 (95% CI, 1.01-7.39). Associations between narrow PA and outcomes continued to be significant after adjustments for various confounders.

CONCLUSIONS

In internal-medicine wards, bioimpedance-derived PA emerged as a predictor of length of hospital stay, hospital readmission, falls, and mortality. The present findings suggest that in the hospital setting, PA assessment could be useful in identifying patients at higher risk who need specific nutritional support.

Outcomes after implementation of an open fracture clinical pathway

INTRODUCTION

Open fractures are associated with high rates of complication, morbidity and high economic costs. To improve outcomes, an open extremity fracture clinical pathway that protocolized surgical management and encouraged multidisciplinary collaboration was implemented in our institution. This study evaluates the clinical outcomes before and after the implementation of the pathway.

METHODOLOGY

Retrospective review of open tibial and femur fractures covering the 2 year periods before and after pathway implementation was conducted. Patient demographics, fracture location, fixation methods and Gustilo-Anderson classification type were recorded. Primary outcomes include complications of wound infection, implant infection, delayed/non-union and flap failure occurring in a 1 year follow-up period. Secondary outcomes include length of hospital stay, time from emergency department (ED) entrance to first wound debridement, time from ED to flap coverage and total number of operations required.

RESULTS

A total of 43 pre-pathway and 46 post-pathway patients were included in this study. There was a significant reduction in length of hospital stay, a 37.5% decrease from a median of 11.2 to 7 days after pathway implementation. There was also a significant decrease in the number of fractures fixed with external fixators from 47 to 26%. No significant differences were found for the other secondary variables. In a subgroup analysis of type III fractures, there was a significant decrease in length of hospital stay as well as the number of operations required. Median length of hospital stay decreased by 46.7% from 15 to 8 days and total number of operations decreased by 50% from a median of four operations to two operations.

CONCLUSION

This study demonstrates that the implementation of an open extremity fracture clinical pathway significantly reduces the proportion of external fixation surgeries, length of hospital stay, and number of operations in patients with open tibial and femur fractures, without compromising complication rates.

Significant Improvement in the Value of Surgical Treatment of Tibial Plateau Fractures Through Surgeon Practice Standardization

INTRODUCTION

It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value.

METHODS

This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities.

RESULTS

Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001).

DISCUSSION

We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

OBJECTIVE

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer.

METHODS

In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge.

RESULTS

The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01).

CONCLUSION

A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

Review of 128 quality of care mechanisms: A framework and mapping for health system stewards

Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.

Inpatient Management of Acute Severe Ulcerative Colitis

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.

Alignment with Indices of A Care Pathway Is Associated with Improved Survival: An Observational Population-based Study in Colon Cancer Patients

BACKGROUND

Causes of variations in outcomes from cancer care in developed countries are often unclear. Australia has developed health system pathways describing consensus standards of optimal cancer care across the phases of prevention through to follow-up or end-of-life. These Optimal Care Pathways (OCP) were introduced from 2013 to 14. We investigated whether care consistent with the OCP improved outcomes for colon cancer patients.

METHODS

Colon patients diagnosed from 2008 to 2014 were identified from the Australian State of Victoria Cancer Registry (VCR) and cases linked with State and Federal health datasets. Surrogate variables describe OCP alignment in our cohort, across three phases of the pathway; prevention, diagnosis and initial treatment and end-of-life. We assessed the impact of alignment on (1) stage of disease at diagnosis and (2) overall survival.

FINDINGS

Alignment with the prevention phase of the OCP occurred for 88% of 13,539 individuals and was associated with lower disease stage at diagnosis (OR = 0.33, 95% confidence interval 0.24 to 0.42), improved crude three-year survival (69.2% versus 62.2%; p < 0.001) and reduced likelihood of emergency surgery (17.7% versus 25.6%, p < 0.001). For patients treated first with surgery (n = 10,807), care aligned with the diagnostic and treatment phase indicators (44% of patients) was associated with a survival benefit (risk-adjusted HR_{non-aligned vs aligned} = 1.23, 95% confidence interval 1.13 to 1.35), better perioperative outcomes and higher alignment with follow-up and end-of-life care. The survival benefit persists adjusting for potential confounding factors, including age, sex, disease stage and comorbidity.Interpretation.This population-based study shows that care aligned to a pathway based on best principles of cancer care is associated with improved outcomes for patients with colon cancer.

FUNDING

None.

What affects length of hospital stay? A case study from Malta

PURPOSE

Hospital length of stay (LOS) is not only a function of patient- and disease-related factors, but is also determined by other health system-wide variables. Managers and clinicians strive to achieve the best possible trade-off between patients' needs and efficient utilisation of hospital resources, while also embracing ethical decision making. The purpose of this paper is to explore the perceptions of the hospital's major stakeholders as to what affects the duration of LOS of inpatients.

DESIGN/METHODOLOGY/APPROACH

Using a data-triangulated case study approach, 50 semi-structured interviews were performed with management, doctors, nurses and patients. Additionally, the hospitals' standard operating procedures, which are pertinent to the subject, were also included in the thematic analysis.

FINDINGS

This study shows that LOS is a multi-dimensional construct, which results from a complex interplay of various inputs, processes and outcomes.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings emerging from a single case study approach cannot be generalised across settings and contexts, albeit being in line with the current literature.

PRACTICAL IMPLICATIONS

The study concludes that a robust hospital strategy, which addresses deficient organisational processes that may unnecessarily prolong LOS, is needed. Moreover, the hospital's strategy must be sustained by providing good primary care facilities within the community set-up, as well as by providing more long-term care and rehabilitation beds to support the hospital turnover.

ORIGINALITY/VALUE

The subject of LOS in hospitals has so far been tackled in a fragmented manner. This paper provides a comprehensive and triangulated account of the complexities surrounding the duration in which patients are kept in hospital by key stakeholders, most of whom were hands-on in the day-to-day running of the hospital under study.

Monitoring length of stay through control charts: a comparative study of diabetic patients

Objective: Monitoring length of stay (LOS) can help medical decision makers identify areas of potential improvements and improve resource management, which results in better quality of care for patients. This study aims to monitor process performance at hospitals by implementing a statistical process control (SPC) approach on LOS.Methods: The study focuses on diabetic inpatients admitted to hospitals in two national healthcare systems. The data used in this study were collected from two hospitals: (1) a 500-bed teaching hospital in Southwest Virginia in the U.S., and (2) a 1100-bed teaching and research hospital located in Ankara, Turkey. I-MR charts were used to analyze the datasets and monitor the variations of LOS.Results: The results of I-MR charts showed that LOS was longer in Turkey than the U.S. LOS was skewed toward minimum values in the U.S. whereas it was spread out in Turkey. The average LOS was 3.27 days (STD = 2.30) in the U.S. while it was 7.28 days (STD = 4.56) in Turkey. The differences in two national healthcare systems may be reflected in the LOS variable.Conclusion: This study implements a control chart-based approach to monitor LOS and detect prolonged hospitalization for diabetic patients. As presented in I-MR charts, there are abnormal LOS observations in each data set. The decision makers and caregivers must analyze I-MR charts to identify either common or special causes of variation. Each abnormal LOS requires a detailed patient-centric analysis. Care providers and decision makers can investigate the root causes of abnormal LOS for each patient by further exploring the characteristics of diabetic patients who had abnormal LOS at hospitals, such as age, preexisting conditions, or the type of medical procedure conducted on each patient.

White Coats at the Coalface: The Standardizing Work of Professionals at the Frontline

This study advances theory on professionals by introducing a novel ‘coalface perspective’ to study frontline professionals’ standardizing work. Our multimethod quantitative and qualitative approach explores when, why and how medical professionals in German university hospitals actively maintain care pathway enactment – a technique to standardize day-to-day medical work – in their everyday patient treatment. Professionals’ actively standardizing their work is an understudied yet highly relevant phenomenon that the established ‘autonomy perspective’ – which covers how professionals resist standardization – falls short of explaining. Introducing a coalface perspective overcomes this shortcoming by uncovering novel links between professionals’ day-to-day problem-driven motivations for standardizing work, the characteristics of everyday situations of frontline professional work and practices of standardizing work at the frontline. This study has implications for research on frontline professionals and coalface-perspective research in general.

Long-term Patient-reported Quality of Life and Pain After a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Retrospective Comparative Cohort Study

Introduction

There is an increase in incidence of hip fractures in the ageing population. The implementation of multidisciplinary clinical pathways (MCP) has proven to be effective in improving the care for these frail patients, and MCP tends to be more effective than usual care (UC). The aim of this study was to analyze potential differences in patient-reported outcome among elderly patients with hip fractures who followed MCP versus those who followed UC.

Materials and Methods

This retrospective cohort study included patients aged 65 years or older with a low-energy hip fracture, who underwent surgery in the Maastricht University Medical Center, Maastricht, the Netherlands. Two cohorts were analyzed; the first one had patients who underwent UC in 2012 and the second one contained patients who followed MCP in 2015. Collected data regarded demographics, patient-reported outcomes (Short Form 12 [SF-12] and the Numeric Rating Scale [NRS] to measure pain), and patient outcome.

Results

This cohort study included 398 patients, 182 of them were included in the MCP group and 216 were in the UC group. No differences in gender, age, or American Society of Anesthesiologists classification were found between the groups. No significant differences were found in SF-12 and the NRS data between the MCP group and UC group. In the MCP group, significantly lower rates of postoperative complications were found than in the UC group, but mortality within 30 days and one year after the hip fracture was similar in both groups.

Discussion

Although the effects of hip fractures in the elderly on patient-reported outcome, pain and quality of life have been addressed in several recent studies, the effects of MCP on long-term outcome was unclear.

Conclusion

A multidisciplinary clinical pathway approach for elderly patients with a hip fracture is associated with a reduced time to surgery and reduced postoperative complications, while no differences were found in quality of life, pain, or mortality.

Effects of Clinical Pathways for COPD on Patient, Professional, and Systems Outcomes: A Systematic Review

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.

Influence of clinical pathways used the hospitals of Traditional Chinese Medicine on patients hospitalized with stroke: a systematic review and Meta-analysis

OBJECTIVE

To evaluate the influence of clinical pathways in the hospitals using the Traditional Chinese Medicine in treatment of stroke in terms of postoperative complications, length of stay (LOS), costs incurred during hospitalization, compared with standard medical care.

METHODS

Medline, Embase, China National Knowledge Infrastructure (CNKI) platforms, Wanfang databases and the Cochrane Central Register of Controlled Trials were searched. The search was performed up to August 2014. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Methodological index for non-randomized studies standard. Meta-analyses were performed using RevMan software, version 5.0.

RESULTS

Six studies met the study inclusion criteria and were included in the Meta-analysis for a total sample of 710 patients. The aggregate overall results showed that shorter length of stay in the clinical pathway group was observed during hospital stay was associated with the use of the clinical pathways. No significant differences were found in other effects.

CONCLUSION

Regardless the possible limitations, our findings show that clinical pathways can significantly reduce LOS. Although there is no clear evidence that clinical pathways can reduce hospital costs, but the cost of hospitalization path group for each included study were lower than the control group.

Variables affecting hospital length of stay: a scoping review

Purpose Tertiary hospitals have registered an incremental rise in expenditure mostly because of the increasing demands by ageing populations. Reducing the length of stay (LOS) of patients within tertiary hospitals is one of the strategies, which has been used in the last decades to ensure health care systems' sustainability. Furthermore, LOS is one of the key performance indicators, which is widely used to assess hospital efficiency. Hence, it is crucial that policy makers use evidence-based practices in health care to aim for optimal LOS. The purpose of this paper is to identify and summarize empirical research that brings together studies on the various variables that directly or indirectly impact on LOS within tertiary hospitals so as to develop a LOS causal systems model. Design/methodology/approach This scoping review was guided by the following research question: "What is affecting the LOS of patients within tertiary-level health care?" and by the guidelines specified by Arksey and O'Malley (2005), and by Armstrong et al. (2011). Relevant current literature was retrieved by searching various electronic databases. The PRISMA model provided the process guidelines to identify and select eligible studies. Findings An extensive literature search yielded a total of 30,350 references of which 46 were included in the final analysis. These articles yielded variables, which directly/indirectly are linked to LOS. These were then organized according to the Donabedian model - structure, processes and outcomes. The resultant LOS causal model reflects its complexity and confirms the consideration by scholars in the field that hospitals are complex adaptive systems, and that hospital managers must respond to LOS challenges holistically. Originality/value This paper illustrates a complex LOS causal model that emerged from the scoping review and may be of value for future research. It also highlighted the complexity of the construct under study.

Does the Implementation of Clinical Pathways Affect Hierarchical Structures Within a Surgical Department? A Qualitative Study

Objective:

To explore effects of the implementation of clinical pathways (CPs) on hierarchical structures within a surgical department.

Summary of background data:

CPs are care plans stipulating diagnostic and therapeutic measures along a time axis for a given condition or procedure. They are widely used in surgery. There is limited evidence to what extent CP implementation has an effect on hierarchical structures within surgical departments.

Methods:

Semistructured individual interviews were conducted with key members of a CP project team in a large academic surgery department. Interviews were carried out by an external researcher to increase the likelihood of obtaining unbiased opinions. Using an interview guide, it was ensured that respondents provided opinions on various issues related to CP implementation, including hierarchical relationships within the department, but also between caregivers and patients. The transcribed text was independently content analyzed by 2 researchers who converged their findings.

Results:

Clinical pathway implementation changed perceived surgical hierarchy from a top-down to a participatory approach. However, it was acknowledged that some form of hierarchy is required to ensure successful clinical pathway implementation. Respondents felt that clinical pathways changed surgical culture from a largely eminence-based to more evidence-based medicine.

Conclusions:

The implementation of CPs potentially affects several dimensions of surgical hierarchy. It changes “traditional” surgical hierarchy and is associated with perception of increased autonomy and competency in junior staff. The clinical approach appears to shift from eminence- to evidence-based medicine. The knowledge about these changes is important for carrying out CP projects in surgery.

Updated panel report: best practices for the surgical treatment of obesity

BACKGROUND

During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce.

METHODS

An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery.

RESULTS

On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel.

CONCLUSION

Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

The Effect of Evidence-Based Nutrition Clinical Care Pathways on Nutrition Outcomes in Adult Patients Receiving Non-Surgical Cancer Treatment: A Systematic Review

Nutritional decline associated with non-surgical cancer treatment has been well documented. The implementation of an evidence-based nutrition care pathway is one approach suggested to improve the nutrition outcomes of this group of patients. We aimed to systematically review published original research to determine whether evidence-based nutrition clinical care pathways, as compared with usual care, improve outcomes for patients receiving non-surgical cancer treatment. The review was registered with PROSPERO (CRD42017048816) and followed PRISMA guidelines. The search strategy was conducted in four databases, and supplemented by an internet search, from inception to October 2016. Study quality was assessed using the Quality Criteria Checklist for Primary Research. Results were synthesized descriptively. Six reports of five studies formed the final library with a range of interventions and control practices investigated across several diagnostic groups. Nutrition outcomes were reported using multiple approaches with either no effect, or in favor of the clinical pathway intervention. Risk of bias was low in two studies with some risk in the remaining three studies. It was not possible to determine whether the effect on nutritional outcomes was attributable to care pathway implementation. The need to extend the evidence base through high-quality clinical trials was evident.

Pharmacists as Interprofessional Collaborators and Leaders through Clinical Pathways

Pharmacists possess pivotal competencies and expertise in developing clinical pathways (CPs). We present a tertiary care facility experience of pharmacists vis-a-vis interprofessional collaboration for designing and implementing CPs. We participated in the development of CPs as leading members of a collaborative team of healthcare professionals. We reviewed literature, aligning it with hospital formulary and institutional standards, and participated in weekly team meetings for six months. Several tools and services were adapted to guide prescribing and standardization of care through time-bound order sets. Fifteen CPs leading to admissions in medical wards were developed and integrated into Computerized Prescriber Order Entry (CPOE) sets. Tools and services included (1) reporting of creatinine clearance to guide optimum dosing; (2) advisory flags for dosing and infusion rates; (3) piloting of medication reconciliation and counseling services before discharge were initiated; (4) Arabic drug leaflets were designed to educate patients; and (5) five CPs were included in pragmatic randomized control trials with a clinical pharmacist as co-investigator. Clinical pharmacists conducted continuous orientation to various healthcare professionals throughout the process. CPs provide unique opportunities for establishing and evaluating patient-centered pharmaceutical services and allow clinical pharmacists to demonstrate interprofessional leadership in collaboration with multidisciplinary teams.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.

OBJECTIVE

The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.

METHOD

A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.

RESULTS

From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).

CONCLUSIONS

Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study

AIMS AND OBJECTIVES

To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI).

BACKGROUND

Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes.

DESIGN

Quasi-experimental study.

METHODS

The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction.

RESULTS

Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age.

CONCLUSIONS

The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes.

RELEVANCE TO CLINICAL PRACTICE

The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care.

The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has substantial economic and human costs; it is expected to be the third leading cause of death worldwide by 2030. To minimize these costs high quality guidelines have been developed. However, guidelines alone rarely result in meaningful change. One method of integrating guidelines into practice is the use of clinical pathways (CPWs). CPWs bring available evidence to a range of healthcare professionals by detailing the essential steps in care and adapting guidelines to the local context.

METHODS/DESIGN

We are working with local stakeholders to develop CPWs for COPD with the aims of improving care while reducing utilization. The CPWs will employ several steps including: standardizing diagnostic training, unifying components of chronic disease care, coordinating education and reconditioning programs, and ensuring care uses best practices. Further, we have worked to identify evidence-informed implementation strategies which will be tailored to the local context. We will conduct a three-year research project using an interrupted time series (ITS) design in the form of a multiple baseline approach with control groups. The CPW will be implemented in two health regions (experimental groups) and two health regions will act as controls (control groups). The experimental and control groups will each contain an urban and rural health region. Primary outcomes for the study will be quality of care operationalized using hospital readmission rates and emergency department (ED) presentation rates. Secondary outcomes will be healthcare utilization and guideline adherence, operationalized using hospital admission rates, hospital length of stay and general practitioner (GP) visits. Results will be analyzed using segmented regression analysis.

DISCUSSION

Funding has been procured from multiple stakeholders. The project has been deemed exempt from ethics review as it is a quality improvement project. Intervention implementation is expected to begin in summer of 2017. This project is expected to improve quality of care and reduce healthcare utilization. In addition it will provide evidence on the effects of CPWs in both urban and rural settings. If the CPWs are found effective we will work with all stakeholders to implement similar CPWs in surrounding health regions.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT03075709 ). Registered 8 March 2017.

Integrated Systems and Continuity in Health Care: A Navigation through the Concepts and Models

This paper aims to share with readers some points on the matter of integration/continuity that we have reached thanks to our professional experience in health-care planning and organization. These points have been confirmed by our experience in the field and by cross-fertilization with other branches of knowledge (sociology, epistemology, management science, education theory, etc.). They represent a difficult process of de-structuring of knowledge, but at the same time opened a path to research, discovery and learning that deeply influenced our way of understanding institutional organizations and has conditioned our operational choices and decisions.

The Impact of System Factors on Quality and Safety in Arterial Surgery: A Systematic Review

OBJECTIVE

A systems approach to patient safety proposes that a wide range of factors contribute to surgical outcome, yet the impact of team, work environment, and organisational factors, is not fully understood in arterial surgery. The aim of this systematic review is to summarize and discuss what is already known about the impact of system factors on quality and safety in arterial surgery.

DATA SOURCES

A systematic review of original research papers in English using MEDLINE, Embase, PsycINFO, and Cochrane databases, was performed according to PRISMA guidelines.

REVIEW METHODS

Independent reviewers selected papers according to strict inclusion and exclusion criteria, and using predefined data fields, extracted relevant data on team, work environment, and organisational factors, and measures of quality and/or safety, in arterial procedures.

RESULTS

Twelve papers met the selection criteria. Study endpoints were not consistent between papers, and most failed to report their clinical significance. A variety of tools were used to measure team skills in five papers; only one paper measured the relationship between team factors and patient outcomes. Two papers reported that equipment failures were common and had a significant impact on operating room efficiency. The influence of hospital characteristics on failure-to-rescue rates was tested in one large study, although their conclusions were limited to the American Medicare population. Five papers implemented changes in the patient pathway, but most studies failed to account for potential confounding variables.

CONCLUSIONS

A small number of heterogenous studies have evaluated the relationship between system factors and quality or safety in arterial surgery. There is some evidence of an association between system factors and patient outcomes, but there is more work to be done to fully understand this relationship. Future research would benefit from consistency in definitions, the use of validated assessment tools, measurement of clinically relevant endpoints, and adherence to national reporting guidelines.

A scoping review of adult chronic kidney disease clinical pathways for primary care

BACKGROUND

Chronic kidney disease (CKD) affects ∼10% of the adult population. The majority of patients with CKD are managed by primary care physicians, and despite the availability of effective treatment options, the use of evidence-based interventions for CKD in this setting remains suboptimal. Clinical pathways have been identified as effective tools to guide primary care physicians in providing evidence-based care. We aimed to describe the availability, characteristics and credibility of clinical pathways for adult CKD using a scoping review methodology.

METHODS

We searched Medline, Embase, CINAHL and targeted Internet sites from inception to 31 October 2014 to identify studies and resources that identified adult CKD clinical pathways for primary care settings. Study selection and data extraction were independently performed by two reviewers.

RESULTS

From 487 citations, 41 items were eligible for review: 7 published articles and 34 grey literature resources published between 2001 and 2014. Of the 41 clinical pathways, 32, 24 and 22% were from the UK, USA and Canada, respectively. The majority (66%, n = 31) of clinical pathways were static in nature (did not have an online interactive feature). The majority (76%) of articles/resources reported using one or more clinical practice guidelines as a resource to guide the clinical pathway content. Few articles described a dissemination and evaluation plan for the clinical pathway, but most reported the targeted end-users.

CONCLUSIONS

Our scoping review synthesized available literature on CKD clinical pathways in the primary care setting. We found that existing clinical pathways are diverse in their design, content and implementation. These results can be used by researchers developing or testing new or existing clinical pathways and by practitioners and health system stakeholders who aim to implement CKD clinical pathways in clinical practice.

Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional and systems outcomes: protocol for a systematic review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a respiratory syndrome characterized by progressive, partially reversible airway obstruction and lung hyperinflation. COPD has a substantial burden which is seen in both patient quality of life and healthcare costs. One proposed method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs aim to guide evidence-based practice and improve the interaction between health services. They bring the best available evidence to a range of healthcare professionals by adapting evidence-based clinical guidelines to a local context and detailing the essential steps in the assessment and care of patients.

METHODS

The aim of this systematic review is to synthesize existing literature on the effects of CPWs for the treatment or management of COPD. We will screen search hits from search strategies developed for a Cochrane Effective Practice and Organisation of Care (EPOC) systematic review on the use of CPWs in primary care and a Cochrane EPOC review on the use of CPWs in hospitals. These searches were run in a range of databases. Studies will be screened independently by two reviewers. All studies identified by our search strategy will be considered regardless of study design as long as they meet the operational definition for clinical pathways developed by Kinsman et al. (BMC Medicine 8, 2010) and focus on the treatment or management of COPD. All included studies will be evaluated for risk of bias utilizing methodologies set out by the Cochrane collaboration. Data regarding patient, professional and systems outcomes will be extracted from all included studies. Data will be presented in both narrative and tabular form.

DISCUSSION

The systematic review outlined in this protocol aims to identify, assess and synthesise all available evidence on the effects of CPWs regarding the treatment and management of COPD. As a result, this review will provide an evidence base for decision makers regarding the practicality, cost effectiveness, patient benefit and best practices regarding the implementation of CPWs for the care of COPD.

Assessing national provision of care: variability in bariatric clinical care pathways

BACKGROUND

The American Society for Metabolic and Bariatric Surgery (ASMBS) Quality Improvement and Patient Safety (QIPS) Committee hypothesized that collecting and sharing clinical pathways could provide a valuable resource to new and existing bariatric programs.

OBJECTIVE

To shed light on the variability in practice patterns across the country by analyzing pathways.

SETTING

United States Centers of Excellence METHODS: From June 2014 to April 2015, clinical pathways pertaining to preoperative, intraoperative, and postoperative management of bariatric patients were solicited from the ASMBS executive council (EC), QIPS committee members, and state chapter presidents. Pathways were de-identified and then analyzed based on predetermined metrics pertaining to preoperative, intraoperative, and postoperative care. Concordance and discordance were then analyzed.

RESULTS

In total, 31 pathways were collected; response rate was 80% from the EC, 77% from the QIPS committee, and 21% from state chapter presidents. The number of pathways sent in ranged from 1 to 10 with a median of 3 pathways per individual or institution. The majority of pathways centered on perioperative care (80%). Binary assessment (presence or absence) of variables found a high concordance (defined by greater than 65% of pathways accounting for that parameter) in only 6 variables: nutritional evaluation, psychological evaluation, intraoperative venous thromboembolism (VTE) prophylaxis, utilization of antiemetics in the postoperative period, a dedicated pain pathway, and postoperative laboratory evaluation.

CONCLUSION

There is considerable national variation in clinical pathways among practicing bariatric surgeons. Most pathways center on Metabolic and Bariatric Surgery Accredited Quality Improvement Program (MBSAQIP) accreditation parameters, patient satisfaction, or Surgical Care Improvement Protocol (SCIP) measures. These pathways provide a path toward standardization of improved care.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

BACKGROUND

Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs.

OBJECTIVE

The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital.

METHODS

It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources.

RESULTS

The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding.

CONCLUSION

The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

[Standard operating procedures (SOPs) for palliative care : Presence and relevance of palliative SOPs within the network of German Comprehensive Cancer Centers (CCCs) funded by the German Cancer Aid]

BACKGROUND

Standard operating procedures (SOPs) can contribute to the improvement of patient care.

OBJECTIVES

Survey the presence and relevance of SOPs for palliative care (PC) within the network of German Comprehensive Cancer Centers (CCCs) funded by the German Cancer Aid.

MATERIALS AND METHODS

In a descriptive survey, palliative care services within 15 CCCs funded by the German Cancer Aid were asked to rate availability and thematic relevance of (1) symptom-related, (2) clinical pathways and (3) measures- and processes-oriented SOPs using a structured questionnaire.

RESULTS

Pain management SOPs were the most common (n =11; 73 %). The most thematic relevance showed SOPs dedicated to pain management, care in the last days of life and delirium and other neuro-psychiatric diseases (each n =13; 87 %), followed by bowel obstruction, dyspnoea, nausea and palliative sedation (each n =12; 80 %).

CONCLUSIONS

There is a wide gap between availability and perceived relevance of palliative care SOPs within the network of German CCCs funded by the German Cancer Aid. It is obvious that there is a need for further development of relevant SOPs in palliative care.

Effectiveness of a Multidisciplinary Clinical Pathway for Elderly Patients With Hip Fracture: A Multicenter Comparative Cohort Study

Introduction:

The use of a multidisciplinary clinical pathway (MCP) for patients with hip fracture tends to be more effective than usual care (UC). The aim of this study was to evaluate the effects of an MCP approach on time to surgery, length of stay, postoperative complications, and 30-day mortality, compared to UC.

Materials and Methods:

This multicenter retrospective cohort study included patients aged 50 years or older with a proximal hip fracture who underwent surgery in one of the 6 hospitals in the Limburg trauma region of the Netherlands in 2012. Data such as demographics, process outcome measures, and clinical outcome were collected.

Results:

This study included a total of 1193 patients (665 and 528 patients in the MCP and UC groups, respectively). There were no differences in patient demographics present. Time to surgery was significantly shorter in the MCP compared to the UC group (19.2 vs 24.4 hours, P < .01). The mean length of stay was 10 versus 12 days (P < .01). In the MCP group, significantly lower rates of postoperative complications were observed and significantly more patients were institutionalized than in the UC group. Mortality within 30 days after admission was comparable between the groups (overall mortality 6%).

Conclusion:

An MCP approach is associated with reduced time to surgery, postoperative complications, and length of stay, without a significant difference in 30-day mortality. The institutionalization rate was significantly higher in the MCP group.

Clinical Pathways: Driving High-Reliability and High-Value Care

Health care in the United States is plagued by errors, inconsistencies, and inefficiencies. It is also extremely costly. Clinical pathways can drive high-value care and high reliability within a health care organization. Clinical pathways are much more than just guidelines or order sets as a part of a protocol of care, however; they must incorporate multiple elements that are critical to their successful implementation and sustainability. Additionally, clinical pathways can be utilized to accomplish strategic goals of the organization while fulfilling the quality, safety, and clinical aspects of the organization's mission.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study.

AUTHORS' CONCLUSIONS

There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital

OBJECTIVE

Standardization of evidence-based care, resource utilization, and cost efficiency are commonly used metrics to measure inpatient clinical care delivery. The aim of our project was to evaluate the effect of pediatric respiratory order sets and an asthma pathway on the efficiency and quality measures of pediatric patients treated with respiratory illnesses in an adult community hospital setting.

METHODS

We used a pre-post study to review pediatric patients admitted to the inpatient setting with the primary diagnoses of asthma, bronchiolitis, or pneumonia. Patients with concomitant chronic respiratory illnesses were excluded. After implementation of order sets and asthma pathway, we examined changes in respiratory medication use, hospital utilization cost, length of stay (LOS), and 30-day readmission rate. Statistical significance was measured via 2-tailed t-test and Fisher test.

RESULTS

After implementation of evidence-based order sets and asthma pathway, utilization of bronchodilators decreased and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011 (P < .05). Asthma LOS decreased from 1.90 days to 1.45 days (P < .05), bronchiolitis LOS decreased from 2.37 days to 2.04 days (P < .05), and pneumonia LOS decreased from 2.3 days to 2.1 days (P = .083). Readmission rates were unchanged.

CONCLUSION

The use of order sets and an asthma pathway was associated with a reduction in respiratory treatment use as well as hospitalization utilization costs. Statistically significant decrease in LOS was achieved within the asthma and bronchiolitis populations but not in the pneumonia population. No statistically significant effect was found on the 30-day readmission rates.

A systematic review of the magnitude and cause of geographic variation in unplanned hospital admission rates and length of stay for ambulatory care sensitive conditions

Background

Unplanned hospital admissions place a large and increasing strain on healthcare budgets worldwide. Many admissions for ambulatory care sensitive conditions (ACSCs) are thought to be preventable, a belief supported by significant geographic variations in admission rates. We conducted a systematic review of the evidence on the magnitude and correlates of geographic variation in ACSC admission rates and length of stay (LOS).

Methods

We performed a search of Medline and Embase databases for English language cross-sectional and cohort studies on 28th March 2013 reporting geographic variation in admission rates or LOS for patients receiving unplanned care across at least 10 geographical units for one of 35 previously defined ACSCs. Forward and backward citation searches were undertaken on all included studies. We provide a narrative synthesis of study findings. Study quality was assessed using a modified Newcastle-Ottawa scale.

Results

We included 39 studies comprising 25 on admission rates and 14 on LOS. Studies generally compared admission rates between regions (e.g. states) and LOS between hospitals. Most of the published research was undertaken in the US, UK or Canada and often focussed on patients with pneumonia, COPD or heart failure. 35 (90 %) studies concluded that geographic variation was present. Primary care quality and secondary care access were frequently suggested as drivers of admission rate variation whilst secondary care quality and adherence to clinical guidelines were often listed as contributors to LOS variation. Several different methods were used to quantify variation, some studies listed raw data, failed to control for confounders and used naive statistical methods which limited their utility.

Conclusions

The substantial geographical variations in the admission rates and LOS of potentially avoidable conditions could be a symptom of variable quality of care and should be a concern for clinicians and policymakers. Policymakers targeting a reduction in unplanned admissions could introduce initiatives to improve primary care access and quality or develop alternatives to admission. Those attempting to curb unnecessarily long LOS could introduce care pathways or guidelines. Methodological work on the quantification and reporting of geographic variation is needed to aid inter-study comparisons.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0964-3) contains supplementary material, which is available to authorized users.