Salvador Cruz-Flores, MD, MPH
Do clinical pathways (CPWs) that guide patient management improve patient outcomes more than usual care?
Included studies compared CPWs, alone or as part of multifaceted interventions if CPWs could be assessed separately, with usual care and had low or medium risk for bias (Effective Practice and Organisation of Care [EPOC] risk for bias tool). CPWs were structured multidisciplinary care plans that included ≥ 3 of the following: guidelines or evidence translated for local use, detailed steps for care, timeframes for criteria-based progression, and standardized care for specific clinical problems in specific populations. Outcomes included in-hospital mortality, in-hospital complications, hospital readmissions, and length of hospital stay.
MEDLINE (to Apr 2008), EMBASE/Excerpta Medica, CINAHL, NHS EED, Global Health, EPOC Register, Cochrane Central Register of Controlled Trials, ISI Web of Science, high-yield journals, conference abstracts, and reference lists were searched for randomized controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies, and interrupted time series. The Database of Abstracts of Reviews of Effectiveness was searched for reviews. Experts were contacted. 19 RCTs and 8 non-RCTs met the selection criteria. 14 RCTs (n = 3721, 2 with low risk for bias) evaluated CPWs alone, and 5 (n = 3546, 2 with low risk for bias) evaluated multifaceted interventions with CPWs. 4 RCTs were conducted in medical units, 3 in medical or surgical intensive care units, 3 in surgical units, 2 in emergency departments, 2 in stroke rehabilitation wards, and 5 in other settings or a mix of settings.
Meta-analysis showed that CPWs alone reduced in-hospital complications more than usual care; groups did not differ for in-hospital mortality or hospital readmissions within 6 months (Table). Data for length of hospital stay were heterogeneous and not suitable for pooling. 9 of 12 RCTs found that CPWs alone reduced length of stay more than usual care. Multifaceted interventions did not differ from usual care for mortality (2 RCTs) or length of hospital stay (3 RCTs); 1 (n = 65) of 3 RCTs found that multifaceted interventions reduced hospital readmissions more than usual care at ≤ 6 months.
Clinical pathways are better than usual care for reducing in-hospital complications but not in-hospital mortality or hospital readmissions.
Clinical pathways (CPWs) alone vs usual care (UC) for patient management*
*NS = not significant; RCT = randomized controlled trial; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from data in article.
Cruz-Flores S. Review: Clinical pathways reduce in-hospital complications but not in-hospital mortality or readmissions. Ann Intern Med. ;153:JC2–12. doi: 10.7326/0003-4819-153-4-201008170-02012
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Published: Ann Intern Med. 2010;153(4):JC2-12.
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