Clinical pathways for secondary care and the effects on professional practice, patient outcomes, length of stay and hospital costs.

BACKGROUND

Clinical pathways (CPWs) are structured multidisciplinary care plans. They aim to translate evidence into practice and optimize clinical outcomes. This is the first update of the previous systematic review (Rotter 2010).

OBJECTIVES

To investigate the effect of CPWs on patient outcomes, length of stay, costs and charges, adherence to recommended practice, and to measure the impact of different approaches to implementation of CPWs.

SEARCH METHODS

For this update, CENTRAL, MEDLINE, and Embase were searched on 25 July 2024. Two trial registries were searched on 26 July 2024, along with reference checking, citation searching and contacting authors to identify additional studies.

SELECTION CRITERIA

We considered two groups of participants: health professionals involved in CPW utilization, including (but not limited to) physicians, nurses, physiotherapists, pharmacists, occupational therapists and social workers; and patients managed using a CPW. We included randomized trials, non-randomized trials, controlled before-after (CBA) studies, and interrupted time-series (ITS) studies comparing (1) stand-alone clinical pathways with usual care, and (2) clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all titles, abstracts and full-text manuscripts to assess eligibility and the methodological quality of included studies using the Cochrane Effective Practice and Organization of Care 'Risk of Bias' tool. Certainty of evidence was assessed by two authors independently. Interventions were scored as 'high', 'moderate' or 'low' for the evidence-based implementation process.

MAIN RESULTS

The update provided 31 additional studies for a total of 58 included studies (24,841 patients and 2027 healthcare professionals). Forty-one (71%) were randomized trials, four (7%) non-randomized trials, four (7%) CBA studies and nine (16%) ITS studies. Forty-nine studies compared stand-alone CPWs to usual care and nine compared multifaceted interventions including a CPW to usual care. Collectively, the risk of bias was high due to potential contamination by healthcare professionals, lack of blinding of patients and personnel, lack of allocation concealment and selective reporting in ITS studies. Stand-alone clinical pathway interventions It is uncertain whether stand-alone CPWs reduce inhospital mortality (13% v 16%: OR 0.79, 95% CI 0.53 to 1.20; P = 0.27; I² = 65%; 7 randomized trials; n = 4603; low-certainty evidence due to serious imprecision and inconsistency) or mortality (up to 6 months) (4% v 3%: OR 1.37, 95% CI 0.72 to 2.60; P = 0.34; I² = 20%; 3 randomized trials, n = 805; low-certainty evidence due to serious risk of bias and imprecision). Stand-alone CPWs likely reduce inhospital complications (10% v 17%: OR 0.57, 95% CI 0.41 to 0.80; P = 0.001; I² = 52%; 11 randomized trials, n = 3668; moderate-certainty evidence due to serious risk of bias). It is very uncertain whether stand-alone CPWs reduce hospital readmissions (up to 6 months) (9% v 13%: OR 0.67, 95% CI 0.44 to 1.03; P = 0.07; I² = 11%; 9 randomized trials, n = 1578; very low-certainty evidence due to serious risk of bias and very serious imprecision). Stand-alone CPWs likely reduce the length of hospital stay compared to usual care (MD -1.12 days, 95% CI -1.60 to -0.65; P < 0.00001; I² = 64%; 21 studies; n = 5201; moderate-certainty evidence due to serious inconsistency). Costs and charges were generally lower in CPWs as indicated by negative MDs in nine studies (10 studies, n = 2113, data not pooled; very low-certainty evidence due to serious indirectness and very serious inconsistency). Stand-alone CPWs may slightly increase adherence to recommended practice compared with usual care (3 randomized studies, n = 573; data not pooled; low-certainty evidence due to serious risk of bias and serious inconsistency). Multifaceted clinical pathway interventions It is uncertain whether multifaceted CPWs reduce inhospital mortality (2 randomized studies, n = 6304, data not pooled; low-certainty evidence due to very serious inconsistency). Multifaceted CPWs may make little or no difference to mortality (up to 6 months) (9% v 8%: OR 1.05, 95% CI 0.88 to 1.25; P = 0.61; I² = 0%; 3 randomized studies; n = 6531; low-certainty evidence due to serious imprecision and serious risk of bias). It is uncertain whether multifaceted CPWs reduce inhospital complications (9% v 23%: OR 0.32, 95% CI 0.12 to 0.87; 1 study, n = 140; low-certainty evidence due to very serious imprecision). It is uncertain whether multifaceted CPWs reduce hospital readmission (up to 6 months) (2 randomized studies, n =1569, data not pooled; low-certainty evidence due to very serious inconsistency), or length of stay (4 randomized studies, n = 1936, data not pooled; low-certainty evidence due to very serious inconsistency), or hospital costs and charges (4 randomized studies, n = 2015, data not pooled; very low-certainty evidence due to very serious imprecision and serious indirectness in outcome measures). It is uncertain whether multifaceted CPWs increase adherence to recommended practice (2 randomized studies, n = 6304, data not pooled, low-certainty evidence due to very serious inconsistency). Key study characteristics The highest proportion of included studies were from the USA (36%), followed by Australia (10%), China (10%), Japan (5%), the UK (5%), Canada (5%), Italy (5%), and Germany (5%). More than half of the included studies tested CPW in general acute wards (53%), followed by emergency departments (17%), intensive care (14%), and extended-stay facilities (10%). The most common clinical conditions were asthma (16%), stroke (10%), mechanical ventilation (9%) and myocardial infarction (7%).

AUTHORS' CONCLUSIONS: Stand-alone CPWs are likely to reduce inhospital complications and length of hospital stay and may slightly increase adherence to recommended practice. There was little conclusive evidence for multifaceted CPWs due to mixed results from a limited number of included studies. It is uncertain whether stand-alone CPWs or CPWs, as part of a multifaceted approach, reduce inhospital mortality, mortality (up to 6 months), hospital readmission (up to 6 months) or costs and charges.