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Clinical Pathways: What They Improve

A clinical pathway is a structured multidisciplinary clinical management tool, usually based on evidence-based practice, for a specific group of patients with a predictable clinical course, in which the different tasks by the professionals involved in the patient care are defined, optimized, sequenced and timed. Therefore, clinical pathways help to standardize care processes (or reduce their variability) for a particular diagnosis or procedure.

Clinical pathways have been touted to improve patient outcomes, enhance efficiency, reduce lengths of stay, and decrease costs. Conceptually at least, I can see all these benefits being realized with pathways that are properly developed and implemented. But do they happen in actual practice? Where is the evidence?

Shedding light on these questions, Rotter and colleagues conducted a Cochrane Collaboration systematic review of the effects of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs1 recently. I’ve summarized their results below. (Also included are the odds ratios and confidence intervals in parentheses to give readers the estimated magnitude of effect, but they can be ignored without losing much meaning.)

From the 20 studies that compared stand alone clinical pathways with usual care, the authors found that:

  • Clinical pathways reduced in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94)
  • Clinical pathways improved documentation (OR 11.95; 95% CI 4.72 to 30.30)
  • There was no evidence of differences in readmissions to hospital or in-hospital deaths.
  • Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions.
  • Overall hospital costs/charges decreased.

Most studies reported decreased length of stay and reduced hospital costs with clinical pathways. However, the authors were not able to conduct a meaningful pooled analysis of results for length of stay and hospital costs due to considerable differences in study design and settings.

Poor reporting of the studies prevented the identification of characteristics common to successful clinical pathways.

In addition, the authors looked at seven studies that compared clinical pathways as part of a multifaceted intervention with usual care. They found no differences between intervention (with clinical pathways) and control (with no clinical pathways) groups.

Commentary

Clinical pathways have been implemented worldwide; however, the results from single trials looking at their effects on a range of measures have been somewhat mixed. By combining the results from these single studies, we get a greater picture on whether pathways are beneficial and in what way.

As this was a Cochrane review, I’m confident the results above were obtained after a rigorous process, which helps to reduce the risk of bias (systematic deviation from the truth).

Overall, the findings of this review were not surprising: in-hospital complications were reduced presumably from the reliable application of evidence-based care, documentation improved considerably, length of stay decreased, and costs were reduced. However, with these results, I would have expected to also find a significant reduction in hospital readmission and in-hospital death rates, the absence of which suggests that these measures are subject to other factors besides clinical management.

Reference

  1. Rotter T, Kinsman L, James EL, 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 of Systematic Reviews 2010, Issue 3. Art.No.:CD006632.
    DOI: 10.1002/14651858.CD006632.pub2.
{ 7 comments… add one }
  • Lim Zhi Yi October 13, 2010, 2:25 pm

    Thank you for your commentary for the above article; i am rather surprised with the result shown that there is no reduction in the hospital readmission and in-hospital death rates if these are the key outcome measures, which leads to my following questions, hope to hear from your professional oppinion:
    1. Besides clinical management, what are the others factors that would potentially contributed to the outcome?
    2. Based on the result of these studies, can we then say that the implementation of clinical pathway, thus evident-based practise will not necessarily improve the clinical outcome?

    • Andy Teh October 14, 2010, 1:27 am

      @Lim Zhi Yi—Many thanks for your comment. “No evidence of differences in readmissions to hospital or in-​​hospital deaths” doesn’t necessarily mean “no reduction in the hospital readmission and in-​​hospital death rates” [italics mine]. There could have been differences in readmissions and deaths in reality but in their analysis, the Cochrane authors did not find any evidence of differences. We should remember that Cochrane reviews use a high standard in calling an effect statistically significant (0.05 level of significance). Therefore, even if there was an observable difference in practice, the statisticians might not be sufficiently convinced!

      The analogy I give my students is a jury trying to figure out whether a person is guilty or not. The presumption is that he is not guilty. (In most scientific research these days, the presumption is that an intervention has no effect.) In order to find the person guilty, the jury needs to find sufficient evidence that the accused person is guilty. (Likewise, researchers need to find sufficient evidence of a difference in effect—this is often done statistically.) Otherwise, the person remains not guilty (i.e. no evidence of difference in effect).

      Patient care outcomes are influenced by a host of different (often interrelated) factors: quality of care, leadership and management, organizational culture, nursing workload, patient adherence to medication regimens and other therapies, patient’s and family’s understanding of the health problem and treatments, quality of the physician-patient relationship, socioeconomic status, etc. (to name but a few)

      Clinical pathways have the potential to improve clinical outcomes—their success depends on a number of things, including: prevalence of the condition (for which the clinical pathway is established) in your setting, whether the condition (or its treatment) poses a risk to patients, cost of treating the condition, predictability of the clinical course, degree to which the condition allows similar care, availability of recommendations of good practice, unexplained variability of care, degree to which professional multidisciplinary agreement and implementation may be achieved, and the level of motivation of professionals from different professions in improving outcomes for the condition.

  • Ahmed M. Alkerm October 24, 2010, 7:43 pm

    really,
    this is an amazing article and discussion.

    • Andy Teh October 26, 2010, 12:13 pm

      @Ahmed M. Alkerm – I’m glad you enjoyed the article. You may like to subscribe to our RSS Feed to stay up-to-date with new articles.

  • dalia mohammed abdulsalm elsayed February 28, 2011, 4:56 am

    thank u for this good topic and i want to ask about how can i take CPHQ from distance

    • Andy Teh February 28, 2011, 12:35 pm

      @dalia mohammed abdulsalm elsayed—Teh & Associates offers distance learning programmes to individuals who are not able to attend our live events. Although we are still testing our online CPHQ training programme, a number of our clients have benefited from materials provided by us via the website, e-mail and even snail mail. Our online CPHQ training programme is expected to be available to the public in the last quarter of 2011.

  • ALABI June 21, 2011, 7:40 pm

    reading through this article,it gave me insights into what I should implement in my place of work.i would also want to know
    1.the effect of clinical pathways on the length of time needed to carry out routine hospital activities
    2.the effect of clinical pathways on the financial turnover of the organization.

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