Overview on the target population and methods used in care pathway projects: A narrative review

BACKGROUND

There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are.

METHODS

A narrative review of the literature published from 2015 to 2019 was performed.

RESULTS

We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported.

CONCLUSIONS

Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.

Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association

Objectives

To give an overview on the use and prevalence of clinical pathways.

Design

Cross-sectional descriptive study.

Study participants

European Pathway Association (E-P-A) contact persons in 23 countries.

Results

Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.

Conclusions

There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.

Is there a future for pathways? Five pieces of the puzzle

In this discussion and opinion paper, the Bureau members of the European Pathway Association present five challenges for the future of care pathways. Pathways will have to be based on the latest available evidence and international databases, and tools will have to be available. If pathways have a future, the organisations should focus on disease-specific oriented care. Evidence-based pathways, which are organised in a disease-specific oriented organisation, can lead to improvement of quality and efficiency but only if we invest in real teamwork. As a fourth challenge, the need for technical support of pathways is presented. The last piece of the future pathway puzzle is the need for patient involvement. Pathways will only lead to continuous improvement if we finally see patients as real partners in care organisation.

Development and validation of a care process self-evaluation tool

Clinical pathways are used as a method of organizing care processes. Although they are used worldwide, the concept remains unclear, with little understanding of what exactly is being implemented. A recent systematic review revealed that, although a tool exists to score the instrumental qualities of clinical pathways, no tools are available to assess how the clinical pathway influences the process of care. These tools are needed for a better understanding of the impact of clinical pathways on the length of hospital stay and patient outcomes. In this study, a Care Process Self-Evaluation Tool (CPSET), based on the clinical pathway concept, for assessing the organization of the process of care has been developed and tested. Qualitative and quantitative methods, involving 885 professionals and patients, were used in the development and validation. The CPSET is a valid and reliable 29-item instrument for assessing how the process of care is organized. The CPSET has five subscales: patient-focused organization, coordination of care, communication with patients and family, cooperation with primary care and monitoring/follow-up of the care process. The CPSET can be used in the audit and accreditation of care processes and will help managers and clinicians to understand better how care processes are organized.