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.
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.