Measuring the impact of clinical pathways

In this article, we explain why measure clinical isolated outcomes is not enough when it comes to ensuring the best care in the long term.

Measuring the impact of clinical pathways

Efforts to improve healthcare quality and providers’ efficiency have resulted in the production of practice guidelines and implementation of clinical pathways. According to a 2019 European Observatory on Health Systems and Policies’ report, the use of clinical pathways has been growing in Europe since the 1990s, beginning in the United Kingdom, and spreading to most European countries. However, the European Pathways Association (EPA) concluded that, within the last decade, their use was low and mainly in acute care settings. The same document reveals that experienced professionals rank improvement of care quality and efficiency among the most important features of clinical pathways.

Feels like walking in a contradiction?

Clinical pathways enable rapid access to evidence-based resources for professionals to support decision-making, treatment, care planning, referral, and follow-up. Additionally, these tools can also improve communication and teamwork in multidisciplinary teams. Last, but not least, clinical pathways have also been reported to mitigate risk, be effective in improving patient care outcomes and reduce cognitive overload.

Some practical examples:

  • Marrie et al. concluded from a study on a critical pathway for community-acquired pneumonia that efficiency has increased without affecting the well-being of patients adversely.
  • Macario et al. reported a decrease in average hospital costs for knee replacement surgery from $21,709 to $17,618.
  • Panella et al. reported a mortality rate reduced from 17% to below 5% in heart failure in-patient.
  • Quaglini et al. showed that clinical pathways enable to reduce the length of stay and treatment complications, leading to a significant difference in resource consumption.

A more recent study, conducted within the Department of Pediatrics of the University of Colorado School of Medicine, discloses physicians’ thoughts about clinical pathways’ benefits, covering all the above-mentioned areas. Thus:

  • Physicians expressed that clinical pathways encourage high-value care by decreasing unnecessary utilization of healthcare resources, emphasizing the evidence, and standardizing care.
  • Physicians recognized that clinical pathways increase quality and reduce costs through promoting resource stewardship, practicing evidence-based medicine, and eliminating variation.
  • Participants emphasized that clinical pathways improve communication among team members and different sites to ensure that everyone is on the same page.
  • Physicians noted that, in addition to using clinical pathways as an educational tool, these resources are advantageous for providers with less clinical experience.
  • Participants concluded that clinical pathways offer the additional benefit of providing practice validation, fostering confidence, and affirming clinical decision-making skills.

Why measure the impact of clinical pathways?

Measuring clinical pathways’ impact provides decision-makers and healthcare teams a means for comparing outcomes resulting from standardized processes implementations within or across organizations, thus, being able to:

  1. Identify and address gaps between real patient care and expected behaviors
  2. Adapt, readjust and optimize clinical pathways according to the insights extracted
  3. Measure outcomes’ progress and its association with different clinical behaviors
  4. Plan and develop health care services
  5. Forecast costs according to specific conditions or actions executed

Essentially, monitor and measure how reality conforms with the clinical pathway promotes the identification of training needs, the quantification of HCPs' performance and medical processes improvement. Actually, if not properly adhered to, clinical pathways implementation will most likely be unsuccessful in enhancing the quality of the care provided.

How to measure: clinical compliance vs. clinical outcomes

Healthcare organizations that already measure clinical compliance with a pathway usually have an incorrect, not updated, or oversimplified view of the actual conduct in a patient careflow. Quality measurement has focused mainly on clinical isolated outcomes of care in specific settings (e.g. length of stay, costs, infection rate, etc.). Although these measurements provide valuable information, the diagnostic and therapeutic actions must be considered as well, that is to say compliance measure.

To achieve all the aforementioned goals, you need more than to look at the results. It is often the case that a hospital measures an outcome, but don’t know which decisions led to that particular result and, by widening the time frame, results fluctuate randomly.

By comparing the collected data with the prevailing clinical pathways, it is possible to identify where the care given has deviated from the expected and quantify the compliance level. In practice, hospitals have information systems to capture the treatment behaviors and the details of a patient treatment journey. By comparing such data with the regulations of a clinical pathway, it is possible to assess the compliance of healthcare professionals to the expected course of care and understand the main deviations.

All in all, which actions were missed should be identified and understood, but also the ones executed even though are not recommended, performed in the incorrect order, or within the improper timing.

Process mining in healthcare management
In many domains, when a process is executed, there are observed discrepancies between the expected and the real behavior and, consequently, in the outcomes. Medical processes are no exception. In this article, we discuss process mining applicability in healthcare management.

Main takeaways:

  • Compliance with the international approved guidelines and best practices is essential to reduce litigation costs, make a shift towards value-based high-quality healthcare, and allow the standardization of care treatments.
  • Clinical pathway compliance and variance analysis is fundamental in every healthcare organization to promote process maturity and process improvement, aiming to monitor and fully understand how the reality conforms to the pathway, for an effective performance assessment.
  • Clinical pathway compliance and variance analysis enables to identify education and training needs, to make patients safer and achieve better outcomes.
  • In case of non-compliant behaviors, healthcare organizations can update their clinical pathways specifications to cover the respective case, or they can impose new mechanisms to enforce the best clinical practices.
  • For healthcare leaders seeking to define the value of different processes, measuring clinical pathways impact offer a means of capturing the factors that most define the value to the patient.

Our role is to bring actionable clinical pathways to hospitals, making them available for healthcare professionals to train and decide. Therefore, reducing the time it takes for scientific innovation to have an impact in care settings, improving patient outcomes, and making organizations more predictable in terms of costs and results.

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References:

[1] Rotter T, de Jong RB, Lacko SE, et al. Clinical pathways as a quality strategy. In: Busse R, Klazinga N, Panteli D, et al., editors. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. (Health Policy Series, No. 53.) 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549262/

[2] Vanhaecht K, Bollmann M, Bower K, et al. Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association.  Journal of integrated Care Pathways. 2006;10(1):28-34. doi:10.1177/205343540601000106

[3] Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA. 2000 Feb 9;283(6):749-55. doi: 10.1001/jama.283.6.749. PMID: 10683053

[4] Macario A, Horne M, Goodman S, Vitez T, Dexter F, Heinen R, Brown B. The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg. 1998 May;86(5):978-84. doi: 10.1097/00000539-199805000-00012. PMID: 9585280.

[5] Panella M, Marchisio S, Di Stanislao F. Reducing clinical variations with clinical pathways: do pathways work? Int J Qual Health Care. 2003 Dec;15(6):509-21. doi: 10.1093/intqhc/mzg057. PMID: 14660534.

[6] Quaglini S, Cavallini A, Gerzeli S, Micieli G, GLADIS Study Group (Guideline Application for the Decision making in Ischemic Stroke). Economic benefit from clinical practice guideline compliance in stroke patient management. Health Policy (Amsterdam, Netherlands). 2004 Sep;69(3):305-315. DOI: 10.1016/j.healthpol.2003.12.015.

[7] O'Hara, K., Tanverdi, M., Reich, J., Scudamore, D. D., Tyler, A., & Bakel, L. A. (2020). Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians' Perspectives of Clinical Pathways. Pediatric quality & safety, 5(2), e270. https://doi.org/10.1097/pq9.0000000000000270

[8] Huang, Z., Dong, W., Ji, L., and Duan, H. (2016). Predictive monitoring of clinical pathways. Expert Systems with Applications, 56:227–241.

[9] Barros, Sebastião. Conformance Checking for Care Pathway Compliance Assessment [Tese]. [Lisboa]: Instituto Superior Técnico; 2018.