A Method to Evaluate Critical Factors for Successful Implementation of Clinical Pathways

Effective Clinical Pathway Improves Interprofessional Collaboration and Reduces Antibiotics Prophylaxis Use in Orthopedic Surgery in Hospitals in Indonesia

Clinical pathways can improve the quality of health services. The effectiveness and impact of implementing clinical pathways are controversial. The preparation of clinical pathways not only enacts therapeutic guidelines but requires mutual agreement in accordance with the roles, duties, and contributions of each profession in the team. This study aimed to investigate the perception of interprofessional collaboration practices and the impact of clinical pathway implementation on collaborative and Defined Daily Dose (DDD) prophylactic antibiotics per 100 bed-days in orthopedic surgery. The Collaborative Practice Assessment Tool (CPAT) questionnaire was used as a tool to measure healthcare’ perceptions of collaborative practice. The clinical pathway (CP) in this study was adapted from existing CPs published by the Indonesian Orthopaedic Association (Perhimpunan Dokter Spesialis Orthopaedi dan Traumatologi Indonesia, PABOI) and was commended by local domestic surgeons and orthopedic bodies. We then compared post-implementation results with pre-implementation clinical pathway data using ANCOVA to explore our categorical data and its influence towards CPAT response. ANOVA was then employed for aggregated DDD per 100 bed-days to compare pre and post intervention. The results showed that the relationships among members were associated with the working length. Six to ten years of working had a significantly better relationship among members than those who have worked one to five years. Interestingly, pharmacists’ leadership score was significantly lower than other professions. The clinical pathway implementation reduced barriers in team collaboration, improved team coordination and organization, and reduced third-generation cephalosporin use for prophylaxis in surgery (pre: 59 DDD per 100 bed-days; post: 28 DDD per 100 bed-days). This shows that the clinical pathway could benefit antibiotic stewardship in improving antibiotic prescription, therefore reducing the incidence of resistant bacteria.

Utilization of BPM+ Health for the Representation of Clinical Knowledge: A Framework for the Expression and Assessment of Clinical Practice Guidelines (CPG) Utilizing Existing and Emerging Object Management Group (OMG) Standards

Clinical Practice Guidelines (CPG), meant to express best practices in healthcare, are commonly presented as narrative documents communicating care processes, decision making, and clinical case knowledge. However, these narratives in and of themselves lack the specificity and conciseness in their use of language to unambiguously express quality clinical recommendations. This impacts the confidence of clinicians, uptake, and implementation of the guidance. As important as the quality of the clinical knowledge articulated, is the quality of the language(s) and methods used to express the recommendations. In this paper, we propose the BPM+ family of modeling languages as a potential solution to this challenge. We present a formalized process and framework for translating CPGs into a standardized BPM+ model. Further, we discuss the features and characteristics of modeling languages that underpin the quality in expressing clinical recommendations. Using an existing CPG, we defined a systematic series of steps to deconstruct the CPG into knowledge constituents, assign CPG knowledge constituents to BPM+ elements, and re-assemble the parts into a clear, precise, and executable model. Limitations of both the CPG and the current BPM+ languages are discussed.

Toward uniform and controlled clinical pathways in cancer care: a qualitative description

QUALITY ISSUE

The definition of clinical pathways (CPs) and their application are heterogeneous. Each center is used to choose whether to adopt this instrument or not and to variably conceive its features We consider CPs as the necessary description of the cancer patient journey and we emphasize their role as the user view of clinical processes rather than a local translation of guidelines.

CHOICE OF SOLUTION

We proposed a unique CPs model for all the centers of our regional network, with the aim of making CPs accountable and comparable. We also established a central quality evaluation.

IMPLEMENTATION

Through a multi-step process, the model was proposed to the 22 Regional centers. Landmark characteristics of the project were: the involvement of hospital administrations; reference to a unique set of guidelines; a peer-review and open evaluation.

EVALUATION

Of the 374 expected CPs, 253 (68%) were received and evaluated. A median number of 131 items were the object of evaluation in each hub center and 77 in each spoke center. About 79.5% items were considered well described, 15.5% were absent and 5.0% partially described. The median percentage of fulfilled indicators was 85.6% in hub CPs and 82.2% in spoke CPs. Although, not all diseases were equally covered through the territory a high degree of homogeneity and a good quality of compilation were achieved.

LESSONS LEARNED

The project was shown to be feasible and achieved its goal. We suggest this process as a functional way for building uniform cancer CPs.

The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic.

OBJECTIVE

This article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery.

METHODS

We performed a retrospective cohort study of surgical patients age ≥ 18 years hospitalized from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing other elective procedures. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay and 30-day readmissions.

RESULTS

We included 823 (470 and 353 in the pre- and postintervention, respectively) colon surgery patients and 3,415 (1,819 and 1,596 in the pre- and postintervention) surgical control patients in the study. Among the colon surgery cohort, there was statistically significant (p = 0.040) decrease in costs of 1.28% (95% confidence interval [CI] 0.06-2.48%) 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. The surgical control group had a nonsignificant (p = 0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to - 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort.

CONCLUSION

Our study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.

Modeling a Clinical Pathway for Contraception

BACKGROUND

The Centers for Disease Control and Prevention (CDC) produced a 72-page document titled "U.S. Selective Practice Recommendations for Contraceptive Use" in 2016. This document contains the medical eligibility criteria (MEC) for contraceptive initiation or continuation based on a patient's current health status. Notations such as Business Process Model and Notation (BPMN) and Decision Model and Notation (DMN) might be useful to model such recommendations.

OBJECTIVE

Our objective was to use BPMN and DMN to model and standardize the processes and decisions involved in initiating birth control according to the CDC's MEC for birth control initiation. This model could then be incorporated into an electronic health records system or other digital platform.

METHODS

Medical terminology, processes, and decisions were modeled in coordination with the CDC to ensure correctness. Challenges in terminology bindings were identified and categorized.

RESULTS

A model was successfully produced. Integration of clearly defined data elements proved to be the biggest challenge.

CONCLUSION

BPMN and DMN have strengths and weaknesses when modeling medical processes; however, they can be used to successfully create models for clinical pathways.

Big-data analysis: A clinical pathway on endoscopic retrograde cholangiopancreatography for common bile duct stones

BACKGROUND

A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation.

AIM

To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196).

RESULTS

At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones (P < 0.001) and incidence of cholangitis complication (P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials (P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) (P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups.

CONCLUSION

Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.

Efficacy of a clinical pathway for patients with thyroid cancer

BACKGROUND

Clinical pathways have been proposed as a way to improve organizational efficiency and maximize patient outcomes. However, little is known as to whether a clinical pathway is effective for thyroid cancer.

METHODS

The study subjects included 216 patients who were managed after clinical pathway implementation and 145 control patients. Length of stay, cost per patient, and nurses' satisfaction were compared in the 2 groups.

RESULTS

Mean length of stay was 0.8 days shorter in the clinical pathway group than in the control group (2.9 vs 3.7 days; P = .023). Cost per patient was also lower in the clinical pathway than in the control group (USD $3953.00 vs USD $4636.00; P < .001). Nurses' overall satisfaction scores improved from 71.6% before to 82.5% after implementation of the clinical pathway and their job characteristics scores increased from 61.1% to 75.0%.

CONCLUSION

Implementation of a clinical pathway for thyroid cancer can improve nurses' satisfaction with reduction of hospital stay and costs.