- Email: [email protected]
Clinical pathways that include guidelines may improve both process and outcome of care
EV I D E NC E -B A S E D H E A L T H C ARE MANAGEME NT
Clinical pathways that include guidelines may improve both process and outcome of care 1. Holtzman J, Bjerke T, Kane R. The effects of clinical pathways for renal transplant on patient outcomes and length of stay. Med Care 1998;36:826d834. 2. Dowsey MM, Kilgour ML, Santamaria NM, Choong PFM. Clinical pathways in hip and knee arthoplasty: a prospective randomised controlled study. Medical Journal of Australia 1999;170:59d62.
PAPER 1 OBJECTIVE To examine the impact of introducing two renal transplant clinical pathways on efficiency of care and patient outcomes.
The authors conclude that more research is needed to improve our understanding of factors that predict effective pathways. They also emphasize that it is important to separate the benefits of the developmental process from those attributable to the implementation of the pathway.
SETTING University of Minnesota Hospital, USA. METHOD Cohorts of patients were compared before, during, and after the development and implementation of two renal transplant clinical guidelines for isolated renal transplant from cadaveric donors (n"170) or from living donors (n"178).
PAPER 2 OBJECTIVE To assess the effectiveness of clinical pathways in improving patient outcomes and decreasing lengths of stay for hip and knee arthroplasty.
LITERATURE REVIEW No explicit strategy; 20 references.
SETTING An Australian, urban tertiary referral university hospital.
OUTCOME MEASURES f Hospital length of stay. f Complications. f Incidence of infection.
METHOD Twelve month randomized prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care.
RESULTS Following the development and implementation of the cadaveric donor pathway, mean length of stay decreased from 17.5 days to 11.8 days ( P"0.008); complication rates fell from 38.1 to 14.8% ( P"0.002) and infections fell from 33.3 to 7.4% ( P"0.001). There were no changes in outcomes in people who received kidneys from living donors. AUTHORS’ CONCLUSIONS The authors accept that difference in the groups’ results reflect inconsistent results obtained from previous evaluations of care pathways. They identify three possible reasons for the difference: (1) the care pathway did not have a beneficial effect on the outcome of cadaveric donation and the improvement was a result of some other, unknown, change; (2) the care pathway for cadaveric donation may have been inherently superior to that for living donors; (3) there may have been greater scope for improvement in cadaveric donation (which usually occurs in unplanned, emergency operations) than in live donation (which is carefully planned and organized).
Commentary Having just completed a Cochrane review on the effectiveness of clinical guidelines where conclusions were often compromised by poor study quality,2 I was hoping to read these papers and find unequivalent evidence that clinical pathways improve patient outcomes. Instead, these studies seem to raise more questions than they answer. Dowsey and colleagues’ study allocated participants randomly to control and intervention groups, but all were cared for in the same hospital and, possibly, by the same health professionals. It is
^ 1999 Harcourt Publishers Ltd
LITERATURE REVIEW No explicit strategy: 16 references. There is a linked Editorial1 with 12 references. PARTICIPANTS 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty and randomly allocated to the clinical pathway (n"92) and the control group (n"71). OUTCOME MEASURES f Duration of stay. f Complication rate. f Readmission rate. RESULTS Clinical pathway patients had a shorter mean length of stay, 7.1 days compared with 8.6 days ( P"0.011). People with a pre-morbid condition had a more significant difference, 7.7 days compared with 11.4 days ( P"0.001). In the pathway group the readmission rate was lower, 4.3% versus 13% ( P"0.06), as was the complication rate, 10.8% compared with 28.1% ( P"0.01). AUTHORS’ CONCLUSIONS A clinical pathway is an effective method of improving patient outcomes and decreasing the length of stay.
possible, then, that there was contamination of the control group by personnel also using the clinical pathway. Furthermore, other interventions, pre-admission clinics and patient information seminars, were taking place and were open to both clinical pathway and control patients. These were found to benefit mobilization and discharge from hospital, but the authors do not give the distribution of control and intervention group patients attending each. If more attendees were in the clinical pathway group, more favorable outcomes may have had nothing to do with the clinical pathway.
Evidence-based Healthcare (1999) 3, 101d102
101
Holzman and colleagues’ study has the same aim, but a different study design. Again, findings are equivocal, with benefit to patients receiving transplants from cadaveric but not living donors. Unfortunately, cadaver and living donor recipients were not comparable at baseline, which may undermine intervention and post-intervention differences, Holzman and colleagues raise the possibility that improvement may be due to processes occurring in the development phase, such as different disciplines meeting together to discuss ways of improving quality, and therefore that implementation may not be necessary. Clearly, more research is needed to determine whether clinical pathways improve professional practice and patient outcomes, similar to the body of research that has shown clinical guidelines to be effective.3 More rigorous research design is required to demonstrate unequivocally that the findings are due to clinical pathways, rather than other interventions occuring at the same time. Randomizing patients is the best way of eliminating bias, but control patients should, ideally, be in a separate site and cared for by staff other than those implementing the clinical pathway. Also, as Holzman and colleagues argue, the effects of
102
Evidence-based Healthcare (1999) 3, 101d102
the development as well as the implementation process need to be investigated separately. Dr Lois Thomas Centre for Health Services Research University of Newcastle upon Tyne, UK
Literature cited 1. Kitchener DJ, Bundred PE. Clinical pathways: a practical tool for specifying, evaluating and improving the quality of clinical practice. MJA 1999; 170: 54d55. 2. Thomas LH, McColl E, Cullum N, Rousseau N, Soutter J, Steen N. Effect of clinical guidelines in nursing, midwifery and the therapies: a systematic review of evaluations. Quality in Health Care 1998; 7: 183d191. 3. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317d1322.
^ 1999 Harcourt Publishers Ltd
Clinical pathways that include guidelines may improve both process and outcome of care 1. Holtzman J, Bjerke T, Kane R. The effects of clinical pathways for renal transplant on patient outcomes and length of stay. Med Care 1998;36:826d834. 2. Dowsey MM, Kilgour ML, Santamaria NM, Choong PFM. Clinical pathways in hip and knee arthoplasty: a prospective randomised controlled study. Medical Journal of Australia 1999;170:59d62.
PAPER 1 OBJECTIVE To examine the impact of introducing two renal transplant clinical pathways on efficiency of care and patient outcomes.
The authors conclude that more research is needed to improve our understanding of factors that predict effective pathways. They also emphasize that it is important to separate the benefits of the developmental process from those attributable to the implementation of the pathway.
SETTING University of Minnesota Hospital, USA. METHOD Cohorts of patients were compared before, during, and after the development and implementation of two renal transplant clinical guidelines for isolated renal transplant from cadaveric donors (n"170) or from living donors (n"178).
PAPER 2 OBJECTIVE To assess the effectiveness of clinical pathways in improving patient outcomes and decreasing lengths of stay for hip and knee arthroplasty.
LITERATURE REVIEW No explicit strategy; 20 references.
SETTING An Australian, urban tertiary referral university hospital.
OUTCOME MEASURES f Hospital length of stay. f Complications. f Incidence of infection.
METHOD Twelve month randomized prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care.
RESULTS Following the development and implementation of the cadaveric donor pathway, mean length of stay decreased from 17.5 days to 11.8 days ( P"0.008); complication rates fell from 38.1 to 14.8% ( P"0.002) and infections fell from 33.3 to 7.4% ( P"0.001). There were no changes in outcomes in people who received kidneys from living donors. AUTHORS’ CONCLUSIONS The authors accept that difference in the groups’ results reflect inconsistent results obtained from previous evaluations of care pathways. They identify three possible reasons for the difference: (1) the care pathway did not have a beneficial effect on the outcome of cadaveric donation and the improvement was a result of some other, unknown, change; (2) the care pathway for cadaveric donation may have been inherently superior to that for living donors; (3) there may have been greater scope for improvement in cadaveric donation (which usually occurs in unplanned, emergency operations) than in live donation (which is carefully planned and organized).
Commentary Having just completed a Cochrane review on the effectiveness of clinical guidelines where conclusions were often compromised by poor study quality,2 I was hoping to read these papers and find unequivalent evidence that clinical pathways improve patient outcomes. Instead, these studies seem to raise more questions than they answer. Dowsey and colleagues’ study allocated participants randomly to control and intervention groups, but all were cared for in the same hospital and, possibly, by the same health professionals. It is
^ 1999 Harcourt Publishers Ltd
LITERATURE REVIEW No explicit strategy: 16 references. There is a linked Editorial1 with 12 references. PARTICIPANTS 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty and randomly allocated to the clinical pathway (n"92) and the control group (n"71). OUTCOME MEASURES f Duration of stay. f Complication rate. f Readmission rate. RESULTS Clinical pathway patients had a shorter mean length of stay, 7.1 days compared with 8.6 days ( P"0.011). People with a pre-morbid condition had a more significant difference, 7.7 days compared with 11.4 days ( P"0.001). In the pathway group the readmission rate was lower, 4.3% versus 13% ( P"0.06), as was the complication rate, 10.8% compared with 28.1% ( P"0.01). AUTHORS’ CONCLUSIONS A clinical pathway is an effective method of improving patient outcomes and decreasing the length of stay.
possible, then, that there was contamination of the control group by personnel also using the clinical pathway. Furthermore, other interventions, pre-admission clinics and patient information seminars, were taking place and were open to both clinical pathway and control patients. These were found to benefit mobilization and discharge from hospital, but the authors do not give the distribution of control and intervention group patients attending each. If more attendees were in the clinical pathway group, more favorable outcomes may have had nothing to do with the clinical pathway.
Evidence-based Healthcare (1999) 3, 101d102
101
Holzman and colleagues’ study has the same aim, but a different study design. Again, findings are equivocal, with benefit to patients receiving transplants from cadaveric but not living donors. Unfortunately, cadaver and living donor recipients were not comparable at baseline, which may undermine intervention and post-intervention differences, Holzman and colleagues raise the possibility that improvement may be due to processes occurring in the development phase, such as different disciplines meeting together to discuss ways of improving quality, and therefore that implementation may not be necessary. Clearly, more research is needed to determine whether clinical pathways improve professional practice and patient outcomes, similar to the body of research that has shown clinical guidelines to be effective.3 More rigorous research design is required to demonstrate unequivocally that the findings are due to clinical pathways, rather than other interventions occuring at the same time. Randomizing patients is the best way of eliminating bias, but control patients should, ideally, be in a separate site and cared for by staff other than those implementing the clinical pathway. Also, as Holzman and colleagues argue, the effects of
102
Evidence-based Healthcare (1999) 3, 101d102
the development as well as the implementation process need to be investigated separately. Dr Lois Thomas Centre for Health Services Research University of Newcastle upon Tyne, UK
Literature cited 1. Kitchener DJ, Bundred PE. Clinical pathways: a practical tool for specifying, evaluating and improving the quality of clinical practice. MJA 1999; 170: 54d55. 2. Thomas LH, McColl E, Cullum N, Rousseau N, Soutter J, Steen N. Effect of clinical guidelines in nursing, midwifery and the therapies: a systematic review of evaluations. Quality in Health Care 1998; 7: 183d191. 3. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317d1322.
^ 1999 Harcourt Publishers Ltd