Co John Patrick T, Johnson Kevin B, Duggan Anne K, Casella James F, Wilson Modena
Massachusetts General Hospital, Center for Child and Adolescent Health Policy, Boston, USA.
Jt Comm J Qual Saf. 2003 Apr;29(4):181-90. doi: 10.1016/s1549-3741(03)29022-5.
Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.
Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.
Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.
临床路径常被用于改善医疗服务，但对医疗质量和治疗结果的影响往往未得到评估。1996年初，约翰霍普金斯儿童中心制定了一项临床路径，以改善对小儿镰状细胞血管闭塞性危象（VOC）的治疗，并采用回顾性前后对照研究来描述该路径引入后医疗质量和治疗结果的变化情况。
在符合条件的入院病例中，43%的病例医生使用了该路径，且使用频率随时间下降。与未使用该路径的患者相比，使用该路径的患者更有可能接受其各项要求的治疗措施（优势比[OR]为1.15 - 2.49）。在路径实施后，即使是未使用该路径的患者，与路径可用之前入院的患者相比，也更有可能接受激励性肺量计检查（OR为1.40）。使用该路径与住院时间延长和口服止痛药物使用时间有关，而再入院率没有变化。
临床路径的使用通过提高对特定治疗措施的依从性改善了医疗质量，但对治疗结果的影响好坏参半。路径可能通过影响潜在的医疗模式来改善所有患者的治疗，包括未接受路径治疗的患者。质量改进委员会必须在路径实施后定期监测治疗结果，以评估加强和完善路径的必要性。
