Author:

Keywords:

clinical pathways, care processes, health services research, quality, efficiency, total joint arthroplasty

Abstract:

Summary Clinicians and healthcare managers give more attention to the organisation of care processes. One of the methods to organise care processes is clinical pathways. Clinical pathways are used worldwide in different kind of settings. Many publications describe positive effects of their implementation. Pathways are mainly used as a tool to improve the quality and efficiency of care processes. Therefore the question was raised: “Whatis the effect of clinical pathways on the organisation of care processes?” The study consists of four phases. In afirst phase, a literature study was performed on instruments to describe differences in clinical pathways. Seven clinical pathway audit tools were analysed. The Integrated Care Pathway Appraisal Tool was evaluated as the best tool available. Because of limitations in these audit tools, it was decided to use during the next phases of the study the implicit knowledge of the pathway facilitators to score if a clinical pathway was present. Secondly, a mix of qualitative and quantitative methods was used to define the characteristics of well organised care processes. In total more than 890 clinicians and healthcare managers from hospitals and primary care, and patients participated in the different phases to describe thesecharacteristics. Based on the characteristics a new tool was developed and validated to measure the organisation of care processes: The Care Process Self Evaluation Tool (CPSET). This 29 item instrument has 5 subscales: (i) the patient focused organisation, (ii) the coordination of the care process, (iii) the communication with patients and family, (iv) thecollaboration with primary care and (v) the follow-up of the care process. The tool was validated in a multicenter study including 142 care processes within the Belgian Dutch Clinical Pathway Network. Thirdly, in a study with 103 care processes we found out that clinical pathways have a significant positive impact on the coordination of care and the follow-up of the care process. Not all clinical pathways are well organised and not all well organised care processes are supported by clinical pathways. Fourthly, in a multicenter clinical trial including 39 organisations and 737consecutive patients with total joint replacement, the relations between the use of clinical pathways, the organisation of care processes (CPSET scores) and risk adjusted patient outcomes were analysed. Organisations using clinical pathways had significant higher scores on four out of five subscales of the CPSET. Only the patient focused organisation subscale was not significant. Clinical pathways lead to significantly lower length of stay and elapsed time-to-discharge. The communication with patients and family came out as one of the most important CPSET subscales forthis patient group. The length of stay was significantly determined by the use of clinical pathways, the coordination of the care process and the communication with patients and family. The elapsed time-to-dischargewas significantly determined by the use of clinical pathways and the coordination of the care process. A significant interaction effect betweenthe use of clinical pathways and the coordination of the care process was found for both risk adjusted in-hospital outcomes. We can conclude that clinical pathways are one of the main methodologies to organise and coordinate care processes but the methodology needs to be further improved. It is a complex intervention which has to be developed and continuously followed up by a team including clinicians, healthcare managers and patients.Based on this study we propose five main recommendations for healthcaremanagers, clinicians and policy makers: (i) Investing in care processesmeans investing in the coordination of care, communication with patients and family, cooperation with primary care, and continuous follow-up ofthe care process, all within a patient-focussed organisation. (ii) Clinical pathways have impact on the organisation of care processes and on patient outcomes but not all clinical pathways are well organised. The actual definition and methodology have therefore been revised. (iii) Patient expectations and characteristics should be further analysed and integrated into actual pathways. (iv) The Care Process Self Evaluation Tool (CPSET) is a validated instrument that can help teams and management to clarify their perspective on the actual organisation of care. This tool should always be used in cooperation with evidence-based performance indicators. Teams that work with clinical pathways have a more logical view of how their care processes are organised. (v) Clinical pathways represent more than the development and implementation of a new document or structure for a care process. Pathways are complex interventions that keep the structure, process, and outcome alive. They must be used as a methodto achieve a result.