One of the main problems characterizing health systems is the great variability of clinical practice which means that patients with similar clinical conditions receive different care. There are also inexplicable differences both in terms of length stays, diagnostic and therapeutic procedures. This raises concern among managers, health professionals, and patients if the clinical practice is based on scientific knowledge.

Individual decision-making under high levels of uncertainty and complexity drives clinical practice into sub-optimal care. Usually, health institutions identify and quantify this through extreme events, such as patient harm due to clinical error. In the United States of America (USA), the cost of clinical error can rise to $ 19 billion a year [1] - a tremendous value that represents only a fraction of the sub-optimal health results.

Clinical Practice Guidelines: general statements to optimize patient care

Driven by Evidence-Based Medicine (EBM) and the benefits of healthcare standardization, during the last decades, several health entities have organized themselves to produce recommendations for clinical practice. Often called clinical practice guidelines (CPG), these are important documents to incorporate scientific evidence in health decision making, summarizing the main recommendations, and operationalizing evidence into daily practice for patient care.

Nowadays, we count more than 10.000 published guidelines. In laying down its definition of CPG [2], the Institute of Medicine (IOM) identifies eight attributes with which all CPG must comply:

  • clarity;
  • explicit documentation and methodology;
  • multidisciplinary development;
  • periodic updating;
  • validity of the guide’s recommendations;
  • applicability to patients;
  • flexibility based on guidelines that avoid unjustifiable dogmas;
  • reliability and reproducibility.

Several examples, provided by different medical specialties, illustrate the benefits of clinical practice guidelines adherence: in heart failure field it reduces readmissions [3-5], while, for example, in controlling sepsis infection, adherence to CPG reduces the risk of in-hospital death by 14%.[6]

Thus, clinical practice guidelines are overarching documents to accelerate research translation into real clinical practice.

General to specific approach: defining a Clinical Pathway

When locally implemented, considering the available resources in a specific healthcare institution, these documents should be denominated as clinical pathways (CPWs). They aim to organize and standardize care processes, thus maximizing patient outcomes and improving organizational efficiency.

The clinical pathway is a care plan based on multidisciplinary scientific evidence, which details the actions, decisions, and criteria for the diagnosis, treatment, follow-up, and referral of a disease or symptom.

Literature points out that clinical pathways have positive effects on health services' quality and efficiency.[7] A retrospective cohort study evaluated an ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery and pointed out a 1.28% decrease in costs per surgical encounter per month over the 18-month postintervention period, amounting to a total savings of $2,730 per patient at the 1-year postintervention period.[8]

It also shows that clinical pathways effectively support evidence-based interventions, translating recommendations to the local level, increasing consensus among professionals, and reducing variations in clinical practice.[9-10]

Although the definition of CP is controversial, in 2010, a team of Cochrane authors defined four fundamental criteria for an orientation to be considered a clinical pathway[11]:

  • inclusion of a multidisciplinary care protocol;
  • channeling of scientific evidence to the local context;
  • granular detail of actions and decision criteria, including one or more protocols;
  • standardization of care procedures / clinical problems for a specific population.

Thus, 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, CPWs cannot be extrapolated from one context to another. They can only be used as guidance for developing another clinical pathway, suiting the new context.

Clinical Practice Guidelines vs. Clinical Pathways: pointing out the main differences

Example given: heart failure diagnosis and treatment

What clinical practice guidelines look like?

  • Guide practitioners with questions to ask and physical signs to check;
  • Point out which treatments to prescribe;
  • May indicate which is the first, second, and third line of treatment.

What a clinical pathway looks like?

  • Details the actors involved in the prescription and performance of the echocardiogram that will determine the reduced ejection fraction;
  • Frames the steps and criteria for performing this exam and the time intervals between prescription, echocardiogram and, later, intervals between diagnosis and the start of therapy;
  • Sets down the inclusion and exclusion criteria of the target population of the health unit to which the clinical pathway refers;
  • Lists the evidence supporting each recommended action or decision process.

Essentially a CPW is a comprehensive protocol, in which the most complete definitions may also include goals specifications, both at the clinical and patient subjective levels, in the provision of care, as well as monitoring and evaluation metrics, and detailed identification of resources, their availability and cost.

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.

Check out how our CPW templates and how UpHill software is being used to design and implement clinical pathways.

References:

[1] Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016 May 3;i2139.

[2] Field MJ, Lohr KN. Guidelines for clinical practice. Development to use. Washington, D.C.: National Academy Press; 1992.

[3] Frankenstein L, Remppis A, Fluegel A, Doesch A, Katus HA, Senges J, et al. The association between long-term longitudinal trends in guideline adherence and mortality in relation to age and sex. European Journal of Heart Failure. 2010;12(6):574–80.

[4] Komajda M, Lapuerta P, Hermans N, Gonzalez-Juanatey JR, van Veldhuisen DJ, Erdmann E, et al. Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey. European Heart Journal. 2005 Aug;26(16):1653–9.

[5] Komajda M, Cowie MR, Tavazzi L, Ponikowski P, Anker SD, Filippatos GS, et al. Physicians’ guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. European Journal of Heart Failure. 2017;19(11):1414–23.

[6] Time to Treatment and Mortality during Mandated Emergency Care for Sepsis | NEJM [Internet]. [cited 2020 Oct 6]. Available from: https://www.nejm.org/doi/full/10.1056/nejmoa1703058

[7] 19. Rotter T, Kinsman L, James EL, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews [Internet]. 2010 [cited 2020 Oct 8];(3). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006632.pub2/full

[8] Austrian JS, Volpicelli F, Jones S, Bernstein MA, Padikkala J, Bagheri A, et al. The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery. Applied Clinical Informatics. 2020;11(1):95–103.

[9] Allen D, Gillen E, Rixson L. The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review. JBI library of systematic reviews. 2009;7(3):80–

[10] Rotter T, Kinsman L, James E, 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 Syst Rev. 2010 Mar 17;(3):CD006632. doi: 10.1002/14651858.CD006632.pub2. PMID: 20238347.

[11] Lawal, A.K., Rotter, T., Kinsman, L. et al. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Med 14, 35 (2016). https://doi.org/10.1186/s12916-016-0580-z