Clinical pathways: Effects on practice, outcomes, and costs

Background: Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimize clinical outcomes while maximizing clinical efficiency. Objectives: To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs. Search Strategy: The authors searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organization of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases including Medline, EMBASE, CINAHL, NHS EED, and Global Health. They also searched the reference lists of relevant articles and contacted relevant professional organizations. Selection Criteria: Randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series studies comparing stand-alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. Data Collection and Analysis: Two review authors independently screened all trials to assess eligibility and methodologic quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. Main Results: Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand-alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio = 0.58; 95% confidence interval, 0.36 to 0.94) and improved documentation (odds ratio = 11.95; 95% confidence interval, 4.72 to 30.30). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly reported outcome measure, with most studies reporting significant reductions. Decreases in hospital costs and charges (measured in U.S. dollars standardized to the year 2000) were also observed, ranging from weighted mean differences of +$261 favoring usual care to -$4,919 favoring clinical pathways. Considerable heterogeneity prevented meta-analysis of length-of-stay and hospital cost results. An assessment of whether lower hospital costs contributed cost shifting to another health sector was not undertaken. Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences was found between intervention and control groups. Authors' Conclusions: Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively affecting length of stay and hospital costs.