*Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Kitakyushu, Fukuoka †School of Health Sciences, University of Occupational and Environmental Health ‡Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan.
Med Care. 2014 Jul;52(7):634-40. doi: 10.1097/MLR.0000000000000146.
Clinical pathways are care plans used by health providers to describe essential steps in the care of patients with specific medical conditions. Clinical implementation of the regional clinical pathways in Japan has spread, and the 2008 fee schedule included a new "regional inter-provider care planning fee" for stroke. However, no evidence regarding the efficacy of the regional clinical pathways for stroke has appeared.
We examined the association of regional clinical pathways on the length of in-hospital stay in patients with stroke. We also examined whether a variation in the length of in-hospital stay for stroke patients between hospitals exists, and if so, the impact of regional clinical pathways on this variation.
Cross-sectional analysis using the Diagnosis Procedure Combination database for the period April 2011 to March of 2012.
A total of 117,180 patients with the diagnosis "cerebral infarction," coded as I63 in ICD10.
Associations of the use of a regional clinical pathway with the length of in-hospital stay (LOS) were estimated by multilevel regression models using a 2-level structure of individuals nested within the 1011 hospitals. The models added both patient-level factors and hospital-level factors that are potentially associated with LOS.
Hospitals administering a regional clinical pathway had a significantly shorter LOS (9.1 d) than hospitals that did not. Approximately 12% of the variation in LOS between hospitals is possibly explained by whether hospitals implement regional clinical pathways. Application of regional clinical pathways at the individual level is associated with a 7.2-day decrease in LOS at the individual level.
These findings suggest that the regional clinical pathways are potentially effective in improving the management of stroke patients and in promoting the consistency of care between hospitals.
临床路径是医疗服务提供者用于描述特定医疗条件下患者护理基本步骤的护理计划。日本的区域临床路径的临床实施已经普及，2008 年的收费标准包括了一项新的“脑卒中跨机构护理计划费”。然而，目前尚未出现有关脑卒中区域临床路径疗效的证据。
我们研究了区域临床路径对脑卒中患者住院时间的影响。我们还研究了医院之间脑卒中患者住院时间是否存在差异，如果存在，区域临床路径对这种差异的影响。
使用 2011 年 4 月至 2012 年 3 月的诊断程序组合数据库进行的横断面分析。
共 117180 例诊断为“脑梗死”的患者，ICD10 编码为 I63。
使用多水平回归模型，通过个体嵌套在 1011 家医院中的 2 级结构，估计使用区域临床路径与住院时间（LOS）的相关性。该模型添加了可能与 LOS 相关的患者水平因素和医院水平因素。
实施区域临床路径的医院的 LOS 显著缩短（9.1 天），而未实施的医院则较长。医院是否实施区域临床路径可能解释了 LOS 之间 12%的差异。在个体水平上应用区域临床路径与个体水平的 LOS 减少 7.2 天有关。
这些发现表明，区域临床路径可能在改善脑卒中患者的管理和促进医院间护理一致性方面具有潜在的有效性。
