Clinical pathways in hospitals.

Decision-making in hospitals has evolved from being opinion-based to being based on sound scientific evidence. This decision-making is recognised as evidence-based practice. Perpetual publication of new evidence combined with the demands of every-day practice makes it difficult for health professionals to keep up to date. Clinical pathways are document-based tools that provide a link between the best available evidence and clinical practice. They provide recommendations, processes and time-frames for the management of specific medical conditions or interventions. Clinical pathways have been implemented worldwide but the evidence about their impact from single trials is contradictory. This review aimed to summarise the evidence and assess the effect of clinical pathways on professional practice (e.g. quality of documentation), patient outcomes (e.g. mortality, complications), length of hospital stay and hospital costs.

Twenty-seven studies involving 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications and improved documentation associated with clinical pathways. Complications assessed included wound infections, bleeding and pneumonia. Most studies reported a decreased length of stay and reduction in hospital costs when clinical pathways were implemented. Considerable variation in study design and settings prevented statistical pooling of results for length of stay and hospital costs. Generally poor reporting prevented the identification of characteristics common to successful clinical pathways.

The authors concluded that clinical pathways are associated with reduced in-hospital complications

Authors' conclusions: 

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

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Background: 

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

Objectives: 

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

Search strategy: 

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

Selection criteria: 

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

Data collection and analysis: 

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

Main results: 

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 11.95: 95%CI 4.72 to 30.30). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results.  An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.

Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

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