Clinical pathways

General Clinical Pathways Guest Reviewers: Edward M. Kwasnik, MD, and Michael Ajemian, MD IMPLEMENTATION OF A CLINICAL PATHWAY DECREASES LENGTH OF STAY AND COST FOR BOWEL RESECTION. Pritts TA, Nussbaum MS, Flesch LV, et al. Ann Surg 1999;230:728 –733. Objective: To examine the effect of a clinical pathway for small and large bowel resections on cost and length of hospital stay. Design: Combined retrospective chart review for prepathway patients and nonran-

domized prospective data base for postpathway patients. Setting: Department of Surgery, University of Cincinnati Medical Center, Cincin-

nati, Ohio. Participants: A prepathway group of 167 patients underwent bowel resection in the

year before pathway implementation. In the year after pathway implementation, patients were either placed in the pathway group (101 patients) or not included in the pathway (69 patients) based on the preference of the attending surgeon. Comparisons were made between groups regarding the length of stay, hospital cost, timing of nasogastric (NG) tube removal and diet advancement, antibiotic use, occurrence of deep venous thrombosis, and mortality. All patients were scored for severity of illness, and 31-day readmission data was tracked. Results: Nonpathway patients were on average younger than were the prepathway or

pathway patients (50.0 vs 57.1 vs 59.6 years; p ⬍ 0.05). No significant difference between groups in All Patient Refined DRG severity of illness scores was noted. Mean postoperative length of stay was significantly less in the pathway group compared with the prepathway and the nonpathway groups (7.7 vs 9.98 vs 9.68 days; p ⬍ 0.05). Likewise, NG tube removal and advancement to a clear liquid and regular diet occurred significantly earlier (p ⬍ 0.05) in the pathway group. The mean hospital cost was significantly less (p ⬍ 0.05) for patients in the pathway group ($13,908.53) vs the nonpathway ($20,835.58) and the prepathway ($19,997.35) groups. No significant differences in morbidity and mortality or hospital readmission rates existed between groups in this study. Conclusions: Standardization of care by implementation of a clinical pathway de-

creased the length of stay and hospital cost in patients undergoing small and large bowel resections at a university medical center.

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REVIEWER COMMENTS

This study illustrated that staff participation in the development and implementation of clinical pathways that standardize care led to decreased use of hospital resources. However, the lack of both randomization and a true control group must be considered when evaluating the comparisons made among groups. In particular, 43% of the pathway patients came from 2 surgeons who were both members of the pathway committee, although 24 surgeons performed bowel resections on the patient population. Consequently, the lack of randomization in assigning the contemporaneous nonpathway group limits its validity as a true control group because this group would potentially benefit from staff awareness of changes in care recommended by the pathway (Hawthorne effect). Another point to consider is that the authors seem to use the terms “charge” and “cost” interchangeably in presenting their financial data. As is well known, hospital costs are difficult to analyze because they include both the costs directly allocable to direct patient care as well as administrative overhead. As a result, they bear no consistent relationship to hospital charges. Because considerable differences exist in reimbursements from third-party payers for similar procedures, a more accurate assessment of the economic efficiency of this pathway should include the actual payments the hospital received for these services as well as the allocation of these funds to fixed versus variable components of the procedure cost.

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REVIEWER COMMENTS

This study focused on noncompliance with clinical guidelines and demonstrated that close monitoring by a nurse manager improved physician compliance with clinical management guidelines designed for stress ulcer and DVT/PE prophylaxis. Several factors seemed to contribute to a compliance rate of only 48% after initial attempts at implementation of the clinical management guidelines. Throughout their training, physicians have been taught to be independent thinkers and to resist attempts to interfere with clinical autonomy. Furthermore, residents who were responsible for writing orders in this institution, frequently changed services, and therefore, they required constant education and supervision in the use of clinical management guidelines. In this study, the role of the nurse manager as a monitor was to educate residents, monitor their feedback, and inform them when they were not in compliance with the clinical pathway. Attending surgeons may be less amenable to this type of supervision than physicians-in-training may be, thereby limiting the effectiveness of this approach in nonteaching hospitals. This study is limited by the use of clinical outcomes as end points of therapy rather than objective standards, such as esophagoscopy and duplex scanning, to define the true incidence of stress ulcers and DVT, respectively. However, the same criteria were used before and after the institution of monitoring. In addition, the degree of cost saving achieved through the decreased use of antacid medications may be offset by the cost of extra work done by the nurse clinical resource manager. REVIEWER COMMENTS

This report presents the successful experience of a community hospital surgeon who designed and subsequently implemented a group of vascular surgery pathways. The results confirm that many long-standing practices related to arterial reconstructions in complex patients may be significantly streamlined, with subsequent cost savings and satisfactory clini-

STRATEGIES TO IMPROVE COMPLIANCE WITH EVIDENCE-BASED CLINICAL MANAGEMENT GUIDELINES. Frankel HL, FitzPatrick MK, Gaskell S, et al. J Am Coll Surg 1999;189:533–538. Objective: To evaluate the rate of physician compliance with 2 evidence-based

clinical management guidelines before and after the institution of continuous surveillance by a nurse clinical resource manager. Design: Physician adherence to clinical management guidelines regarding prophylaxis for DVT/pulmonary embolism (PE) and stress ulcers in trauma patients were compared by chart review before and prospectively after initiation of compliance monitoring by a nurse clinical resource manager. Setting: Division of Traumatology and Surgical Critical Care, University of Penn-

sylvania Medical Center, Philadelphia, Pennsylvania. Participants: Data were collected on 84 patients preinstitution of continuous mon-

itoring and 116 patients postinstitution of monitoring. The rates of DVT/PE and gastrointestinal bleedings from stress ulceration were monitored for both groups. The additional cost for noncompliance with the clinical management guidelines was also recorded. Results: Compliance with the clinical management guidelines was 48% preinstitu-

tion and 74% postinstitution of surveillance. No significant difference in the rate of DVT, PE, or stress ulcer occurred in the preinstitution and postinstitution groups. The total hospital cost of noncompliance with the stress ulcer clinical management guidelines was $22,760.35 for 2 months. Conclusions: Implementation of continuous physician surveillance by a clinical resource manager improved compliance with 2 clinical management guidelines at a level I trauma center.

DO CLINICAL PATHWAYS FOR MAJOR VASCULAR SURGERY IMPROVE OUTCOMES AND REDUCE COST? Collier PE. J Vasc Surg 1997;26:179 –185. Objective: To determine whether the implementation of clinical pathways for pa-

tients undergoing vascular procedures in a community hospital would decrease length of stay and reduce charges when compared with Medicare standards. Design: Clinical pathways that emphasized outpatient arteriography, same-day admission, selective intensive care unit utilization, early ambulation, and physical therapy were developed from a review of the literature as well as institutional experience with vascular procedures. Clinical outcome and financial data were collected prospectively

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for a nonrandomized clinical series after pathway implementation and compared with Medicare cost and utilization standards. Setting: Community hospital, Sewickley Valley Hospital, Sewickley, Pennsylvania. Participants: All Medicare patients undergoing carotid endarterectomy (112

points), aortic/renal reconstructions (42 points), and lower extremity bypass (130 points) over a 25-month period. Results: Arteriography was limited to 7% of carotid patients and 24% of aortic

reconstruction patients. Same-day admission was common (95%), and the intensive care unit was limited to 17% of the entire series, primarily for aortic procedures. Lengths of stay were significantly reduced compared with Medicare standards, and complication rates were acceptable. For the entire series, Medicare reimbursements exceeded charges by $1,256,000. Conclusions: Clinical pathways significantly reduce the length of stay and inpatient

charges for major arterial reconstructions while maintaining high standards of care.

REVIEWER SUMMARY Over the past decade, clinical pathways have become ubiquitous features of the health care landscape. Nevertheless, many practitioners still regard them merely as compendiums of “standing orders” that simplify care of the average surgical patient. On a more fundamental level, however, they are processes for gathering, analyzing, and organizing the evidence (from both the literature and the local clinical environment) required for the practice of evidence-based medicine. Guidelines for pathway development2,3 suggest that a multidisciplinary team of physicians and nurses collaborate with representatives of clinical and administrative support services, not necessarily to reinvent the wheel, but to examine established local practice patterns in the context of benchmarks from the literature or from professional societies. This approach, which rests on the principle of “what’s right,” not “who’s right,” is based on mutual education and can often overcome a natural resistance to changing clinical habits that have supposedly stood the test of time.4 Ideally, a pathway evolves from the synergy between the constituencies critical to its successful implementation. Each is afforded an opportunity for input and thus buys into the final product. Consequently, sources of unnecessary variation are identified and minimized, desired clinical outcomes are defined, and the institutional and financial resources needed to achieve these goals are quantified. Equally important, a process of monitoring the implementation, performance, and subsequent modification of the pathway is established at this time. As demonstrated in the previously reviewed reports, surgical pathways may be procedure based (eg, colon resection or vascular reconstruction) or disease or symptom based (eg, trauma or abdominal pain). In our institutional experience, the most return for the effort expended came from standardizing procedures that were high volume or resource intensive. Pathway development proceeded rapidly for the bulk of elective “bread and butter” ambulatory general surgical operations, such as hernia repair, breast biopsy, and laparoscopic cholecystectomy. Documentation of financial efficiencies, low complication rates, and high degree of patient satisfaction allowed the pathway concept to be accepted across the spectrum of surgical specialties This experience also provided a framework for development of pathways dealing with more complex procedures and clinical problems. An added benefit of participation in pathway development was an introduction to the current economics of health care delivery, a topic viewed as virtually unprofessional by former generations of surgeons. The contemporary managed care environment, however, has required an increased accountability for utilization of healthcare resources by surgeons,5 who must also compete with institutions and their colleagues for 560

REVIEWER COMMENTS (Con’t)

cal outcomes. Several factors should be carefully considered, however, in extrapolating this experience to other institutions. In the first place, the entire undertaking was apparently carried out by a surgeon who did not have to enlist the support of other practitioners in implementing the project. Secondly, the study included a wide range of procedures in patients who varied in their comorbidities and operative risk. Although the overall results were favorable, stratification of patients according to their indications for surgery as well as complexity of illness, as in other series,1 may have identified subsets of patients for whom the pathways were less effective. Finally, financial data were tabulated as charges rather than as institutional costs, which are much harder to define. The cost savings, therefore, are relative at best when compared with the actual financial impact on the institution. Again, it is important to realize that a more accurate assessment of “charges” would include the actual payments the hospital received for services as well as the allocation of funds to fixed versus variable components of the procedure cost. In addition, moving arteriography to the outpatient setting, earlier discharge to intermediate care facilities and use of home care services may not necessarily reduce costs to the overall health care delivery system, but merely shift them to a different setting.

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compensation based on complex reimbursement schedules. It is only by first-hand analysis of the often disproportionate relationships among charges, cost, and reimbursement that surgeons can balance their fiscal responsibilities to the health care delivery system with their roles as advocates for proper patient care. Familiarity with the principles of cost containment and pathway development has recently been emphasized as an essential component of surgical training. Because house staff are responsible for most orders (and, consequently, costs) in academic institutions, we have found that inclusion of surgical residents on the pathway team is an ideal mechanism for introducing them to the practice of evidence-based medicine and the rational utilization of clinical resources. Compliance with pathways has been facilitated, resulting in cost savings for the institution and an achievement of important educational goals for the surgical training program.

EDWARD M. KWASNIK, MD MICHAEL AJEMIAN, MD Department of Surgery Waterbury Hospital Health Center Waterbury, Connecticut PII S0149-7944(00)00284-1

REFERENCES 1. Stanley AC, Barry M, Scott TE, et al. Impact of a critical pathway on postoperative

length of stay and outcomes after infrainguinal bypass J Vasc Surg 1998;27:1056 – 1065. 2. Hoyt DB. Clinical practice guidelines. Am J Surg 1997;173:32–34. 3. Gadacz TR, Adkins RB, O’Leary, JP. General surgical clinical pathways: an intro-

duction. Am Surg 1997;63:107–110. 4. Greco PJ, Eisenberg JM. Changing physician’s practices. N Engl J Med 1993;329:

1271–1274. 5. Taheri PA, Butz D, Griffes LC, Morlock DR, Greenfield LJ. Physician impact on

the total cost of care. Ann Surg 2000;231:432– 435.

Geriatrics Geriatric Surgery Guest Reviewer: Michael D. Grossman, MD REVIEWER COMMENTS

This study was selected for review because it is widely quoted and because it focuses upon surgical critical care. The paper was presented at the Western Surgical Association in 1992 and the printed discussion is noteworthy. Many problems with the authors’ conclusions are pointed out. In general, the nonagenarian group had greater severity of illness (higher

SURGICAL INTENSIVE CARE IN THE NONAGENERIAN: NO BASIS FOR AGE DISCRIMINATION. Marguiles DR, Lekawa ME, Bjerke S, Hiatt JR, Shabot MM. Arch Surg 1993;128:753–758. Objective: To investigate the effect of extreme age on outcome from surgical inten-

sive care. Design: Prospective data collection with retrospective analysis. Setting: A 20-bed noncardiac surgical intensive care unit in a 1201-bed tertiary care

medical center. Participants: Nonagenarians were compared with patients younger than 90 years.

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