Clinical decisions will always be surrounded by some degree of uncertainty, related to the absence of three types of information: technical data (technical uncertainty), data on patient values (personal uncertainty), and context data (conceptual uncertainty).[1]

  • Technical uncertainty arises from inadequate or incomplete scientific data, since finding relevant evidence to provide the right answer to a specific question can be challenging;

e.g.: which medicine to prescribe?

  • Personal uncertainty arises from not knowing patients' wishes and it includes not only uncertainty that arises from real outcomes of given probabilities but also patients’ desire or degree of interest regarding the outcomes;

e.g.: how well informed is a particular patient about treatment options and possible outcomes?

  • Conceptual uncertainty arises from the problem of applying abstract criteria to concrete situations;

e.g.: how to apply diagnosis criteria in a patient with an atypical presentation?

What are the consequences?

  • It causes anxiety in patients [2] and physicians;[3]
  • It leads to suboptimal care;[4]

Using Clinical Pathways to mitigate uncertainty and to promote efficiency

It is possible to mitigate technical and conceptual uncertainty by making available - in the time and space in which clinical decision-making happens - detailed, updated, multidimensional, and reliable information related to a specific disease.

Decision-making in hospitals has evolved from being opinion-based to being based on sound scientific evidence. This decision-making framework is recognized as evidence-based medicine, which “integrates the best external evidence, with individual clinical expertise and patients’ choice”. [5] Although patient outcomes are improved when the up-to-date research evidence is put into practice, failure to translate research into practice is a refractory problem.

Transforming general clinical practice guidelines into clinical pathways represents an efficient way to do this. In a health organization looking for continuous quality improvement, defining, designing, and adopting clinical pathways are critical actions to standardize care, to align resources in favor of patients' health, to monitor quality, and to provide the basis for continuous quality improvement activities.

All in all, clinical pathways are document-based tools that provide a link between the best available evidence and clinical practice. They provide recommendations, processes, and timeframes for the management of specific medical conditions or interventions, taking into consideration the available resources of a specific provider.[6]

Creating your own clinical pathways

As mentioned before, clinical pathways represent the translation of one or more clinical practice guidelines to the operational reality, namely the available resources and infrastructures, and the population served by a given health unit. By contrast to clinical practice guidelines, they cannot be extrapolated from one context to another. They can only be used as guidance for developing another clinical pathway, suiting the new context.

So, when starting to design a clinical pathway strategy to be followed by healthcare professionals of a specific healthcare unite, you should keep in mind:

  • Your unit-specific goals:  
    which areas would you like to improve in your hospital? What are your priorities?
  • Available resources:  
    which medical specialties exist in your hospital? How many professionals do you have? Which technical resources do you have available?

Answers to the previous questions will help to define how complete your pathway should be.

At UpHill, we structure pathways in 4 different levels:

From a hospitaller perspective ideally, all levels should be covered on clinical pathways. However, it’s absolutely unnecessary to add complexity to a pathway if, a priori, you know that you predominantly focus your activity on treatment or if your staff’s doubts reside on pharmacological issues.


A closer look: two different approaches in practice

Below, we’ll give you two examples of how to adapt the granularization level of your pathways.  

1) Diabetes Mellitus type 2

Over 33 million [7] people in the European Union (EU) suffer from diabetes. According to the International Diabetes Federation data, the absolute number of diabetics in the EU will rise from approximately 33 million in 2010 to 38 million in 2030. [7] Globally, the number of people with diabetes rose from 108 million in 1980 to 422 million in 2014, and between 2000 and 2016, there was a 5% increase in premature mortality from diabetes. [8] The absolute global economic burden will increase from the U.S. $1.3 trillion in 2015 to $2.1 trillion by 2030.[9]

Under the given circumstances, Diabetes Mellitus type 2 pathway covers points 1, 2, and 3 (diagnosis, treatment, and clinical follow-up), providing a global and comprehensive approach to the disease:

  • It supports clinical decisions for diagnosis;
  • It guides physicians’ prescription for both non-pharmacological and pharmacological treatments;
  • It anticipates complications and helps to refer patients to other specialists.

2) COVID-19 diagnosis

Since the recognition of COVID-19 as a pandemic by the World Health Organization, several measures have been taken to prevent and contain transmission of the SARS-CoV-2 virus. These measures included a standardized approach to test suspected cases of COVID-19, by the Standard 019/2020 defined by the Directorate-General for Health (DGS).

UpHill translated this standard into an interactive clinical pathway making it more intuitive, efficient, and less time-consuming for clinicians to follow the guideline. This pathway is extremely different from the one we’ve been talking about before: it covers just the first point (diagnosis), in order to guide physicians on who should be tested or not, focusing just on this specific clinical issue.

Main takeaways:

  1. Different needs form healthcare units lead to different levels of granularity in pathways
  2. Comprehensiveness is not a synonym for complexity;
  3. To particularize a pathway on a specific need doesn’t mean that the pathway is incomplete;

If you don't have the resources needed to develop clinical pathways, consider finding a partner to help you or buying pre-made templates. UpHill has a medical crowd covering several specialists which allows us guaranteeing excellent quality standards regardless of the scope of the contents.

References:

[1] Beresford EB. Uncertainty and the shaping of medical decisions. Hastings Cent Rep. 1991 Jul-Aug;21(4):6-11. PMID: 1938352.

[2] Johnson CG, Levenkron JC, Suchman AL, Manchester R. Does physician uncertainty affect patient satisfaction? J Gen Intern Med. 1988 Mar-Apr;3(2):144-9. doi: 10.1007/BF02596120. PMID: 3357071.

[3] Katz J. Why doctors don't disclose uncertainty. Hastings Cent Rep. 1984 Feb;14(1):35-44. PMID: 6715153.

[4] Braithwaite Jeffrey. Changing how we think about healthcare improvement BMJ 2018; 361 :k2014

[5] Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ (Clinical research ed). 1996 Jan 13;312(7023):71–2.

[6] 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] European Comission | EU research on diabetes | [internet] available at https://ec.europa.eu/info/research-and-innovation/research-area/health-research-and-innovation/diabetes_en

[8] WHO | Diabetes | [internet] available at https://www.who.int/news-room/fact-sheets/detail/diabetes

[9] Bommer C, Sagalova V, Heesemann E, Manne-Goehler F, Atun R, Bärnighausen T, Davies J,  Vollmer S. Global Economic Burden of Diabetes in Adults: Projections From 2015 to 2030 Diabetes Care May 2018, 41 (5) 963-970; DOI: 10.2337/dc17-1962