Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES: Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care. METHODS: A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines. RESULTS: The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively. CONCLUSION: A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.     

Effects of introducing an integrated care pathway in an acute stroke unit

BACKGROUND AND PURPOSE: integrated care pathways are often implemented to guide acute stroke therapy and improve organisation of care, but there is not sufficient evidence to support their routine use. We sought to evaluate the effects of introducing an integrated care pathway for acute stroke. METHODS: we performed a before-and-after study. The 'before' (control) group comprised 154 consecutive stroke patients admitted to the acute stroke unit over a 9-month period. The 'after' (intervention) group comprised 197 consecutive patients admitted to the same unit over a 9-month period in the year after the introduction of the integrated care pathway. Effectiveness was assessed with a variety of measures: quality of documentation; process of care; occurrence of complications; death and discharge destination. Results were adjusted for case mix using a validated model. RESULTS: the baseline characteristics of the two groups were similar, although there were more total anterior circulation strokes (29% versus 18%, P = 0.005) and fewer partial anterior circulation strokes (30% versus 42% P = 0.04) in the intervention group. In the intervention group, we found that urinary tract infections were significantly less frequent (OR 0.37, CI 0.15-10.91) and the quality of several aspects of care (e.g. CT scanning < 48 hours) and documentation were significantly better. However, there were no significant differences in deaths, discharge destination, or length of stay between the two groups. CONCLUSION: this before-and-after study has provided further evidence that introducing an integrated care pathway for acute stroke may improve the quality of documentation and process of care, and reduce the risk of certain post-stroke complications.     

The development and use of a method to compare the costs of acute stroke across Europe

BACKGROUND: there is a need for more information on the costs of different ways of managing stroke. Methods to compare the costs of stroke care in different countries have not been previously developed. OBJECTIVE: to develop and use a method to compare the costs of acute stroke care across Europe. SETTING: acute hospitals in 13 different European centres. SUBJECTS AND METHODS: we included in the study stroke patients hospitalized during 1996-7 at 13 centres across Europe (n=2072). We recorded the duration of acute hospital stay and use of investigations. Mean costs for each centre were predicted using linear regression analysis to adjust for case-mix differences. RESULTS: the average acute hospital stay ranged from 9 days (Spain) to 35 days (UK; P < 0.001). The predicted mean cost of treating conscious, continent men aged > 74 ranged from $220 (95% confidence interval 191-254) in Latvia to $5164 (4294-6191) in Austria. CONCLUSIONS: differences in the acute costs of stroke exist across Europe because of differences in clinical practice and unit costs. This methodology will be used to capture the costs incurred by a broad range of care providers. These estimates will then be suitable for using in cost-effectiveness analysis.     

Does an integrated care pathway improve processes of care in stroke rehabilitation? A randomized controlled trial

OBJECTIVE: to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation. DESIGN: comparison of processes of care data collected in a randomized controlled trial. PARTICIPANTS: acute stroke patients undergoing rehabilitation randomized to receive integrated care pathways management (n=76) or conventional multidisciplinary care (n=76). MEASUREMENTS: proportion of patients meeting recommended standards for processes of care using a validated stroke audit tool. RESULTS: integrated care pathways methodology was associated with higher frequency of stroke specific assessments, notably testing for inattention (84% versus 60%; P=0.015) and nutritional assessment (74% versus 22%, P<0.001). Documentation of provision of certain information to patients/carers (89% versus 70%; P=0.024) and early discharge notification to general practitioners (80% versus 45%; P<0.001) were also more common in this group. There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group. CONCLUSION: integrated care pathways may improve assessment and communication, even in specialist stroke settings.     

Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care.

OBJECTIVES: To evaluate the outcome and cost of transfer to a nursing-led inpatient unit for 'intermediate care'. The unit was designed to replace a period of care in acute hospital wards and promote recovery before discharge to the community. DESIGN: Randomized controlled trial comparing outcomes of care on a nursing-led inpatient unit with the system of consultant-managed care on a range of acute hospital wards. SETTING: hospital wards in an acute inner-London National Health Service trust. SUBJECTS: 175 patients assessed to be medically stable but requiring further inpatient care, referred to the unit from acute wards. INTERVENTION: 89 patients were randomly allocated to care on the unit (nursing-led care with no routine medical intervention) and 86 to usual hospital care. MAIN OUTCOME MEASURES: Length of hospital stay, discharge destination, functional dependence (Barthel index) and direct healthcare costs. RESULTS: Care in the unit had no significant impact on discharge destination or dependence. Length of inpatient stay was significantly increased for the treatment group (P=0.036; 95% confidence interval 1.1-20.7 days). The daily cost of care was lower on the unit, but the mean total cost was pound sterlings 1044 higher-although the difference from the control was not significant (P=0.150; 95% confidence interval - pound sterlings 382 to pound sterlings 2471). CONCLUSIONS: The nursing-led inpatient unit led to longer hospital stays. Since length of stay is the main driver of costs, this model of care-at least as implemented here-may be more costly. However, since the unit may substitute for both secondary and primary care, longer-term follow-up is needed to determine whether patients are better prepared for discharge under this model of care, resulting in reduced primary-care costs.     

急性脑卒中患者的医疗费用构成及相关影响因素研究

目的　为探明脑卒中患者临床费用构成比及相关影响因素。方法　分别对 96例脑卒中患者的总费用进行构成比分析及 6 9例脑梗死患者费用影响因素进行多元回归分析 ,筛选出主要因素后 ,对这些主要因素与总费用之间关系进行单因素分析。结果　 (1)脑卒中患者总费用 80 %用在药费、护理费和床位费。 (2 )影响费用的主要因素为住院天数、入院时MESSS评分、治疗方式和意识障碍。结论　影响费用的主要因素是住院天数、入院时MESSS评分、治疗方式 ,选择最佳的治疗方式、减少住院天数是降低脑卒中患者费用的关键。     

Costs of hospital care for HIV-positive and HIV-negative patients at Kenyatta National Hospital, Nairobi, Kenya

OBJECTIVE: To record the costs of hospital care for HIV-positive and -negative patients in Nairobi, and identify costs paid by patients per admission. DESIGN: Cost data were collected on inpatients enrolled in a linked clinical study using standardized costing methods. SETTING: Kenyatta National Hospital, Nairobi's main district hospital. PATIENTS: Consecutive adult medical admissions to one ward over 14 weeks who consented to enrollment; tertiary referrals were excluded. MAIN OUTCOME MEASURE: Average length of stay and cost per patient admission. RESULTS: The hospital costs of 398 patients (163 HIV positive; 33 with clinical AIDS) were analysed. The mean length of stay was 9.3 days and the mean cost per patient admission was US$163. There was no significant difference in costs or mean lengths of stay between HIV-positive and -negative groups, nor were the costs and lengths of stay for clinical AIDS patients significantly different to those for HIV-positive patients without AIDS. The patient charges paid to the hospital per admission, recorded for 344 patients, were on average US$61; and did not differ by HIV status. CONCLUSION: The similar cost patterns for inpatient care irrespective of HIV status or clinical AIDS probably reflects the limited provision of care beyond basic clinical services. Length of stay rather than differing treatment regimes thus appears to be the main cost driver. Private costs of medical care were high and were likely to pressurize households. When resources are limited, the introduction of new, more costly therapies needs careful planning. The study provides cost information for planning care services in resource-poor settings.     

An economic evaluation on the clinical pathway for gastrectomy]

OBJECTIVE: To analyze the costs of gastrectomy patients treated with the clinical pathway. PATIENTS AND METHODS: Seventy-six patients (path group 44, control 32) had undergone gastrectomy in our hospital in 2001. The clinical pathway included the same care map. Treatment costs were estimated from medical cost receipt data. The economical analysis was performed from the point of the direct cost payer's view. RESULTS: The length of hospital stay in the path group was 27.1 +/- 5.9 days and decreased 8.3 days in comparison with the control(p < 0.001). The cost of the path group was 145.290 +/- 23.773 points and 19.278 points less than the control(p < 0.005). In the path group the operation case per bed was increased 30% and the cost per bed was also increased 15% more than the control. CONCLUSIONS: The implementation of the clinical pathway decreased the length and the cost of hospital stay. The clinical pathway is effective to use the hospital resources, such as bed.     

Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference?

OBJECTIVE: To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status. METHODS: Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways. RESULTS: Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1). CONCLUSION: Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.     

Using a clinical pathway and education to reduce inappropriate prescribing of enoxaparin in patients with acute coronary syndromes: a controlled study

AIMS: To evaluate efficacy of a pathway-based quality improvement intervention on appropriate prescribing of the low molecular weight heparin, enoxaparin, in patients with varying risk categories of acute coronary syndrome (ACS). METHODS: Rates of enoxaparin use retrospectively evaluated before and after pathway implementation at an intervention hospital were compared to concurrent control patients at a control hospital; both were community hospitals in south-east Queensland. The study population was a group of randomly selected patients (n = 439) admitted to study hospitals with a discharge diagnosis of chest pain, angina, or myocardial infarction, and stratified into high, intermediate, low-risk ACS or non-cardiac chest pain: 146 intervention patients (September-November 2003), 147 historical controls (August-December 2001) at the intervention hospital; 146 concurrent controls (September-November 2003) at the control hospital. Interventions were active implementation of a user-modified clinical pathway coupled with an iterative education programme to medical staff versus passive distribution of a similar pathway without user modification or targeted education. Outcome measures were rates of appropriate enoxaparin use in high-risk ACS patients and rates of inappropriate use in intermediate and low-risk patients. RESULTS: Appropriate use of enoxaparin in high-risk ACS patients was above 90% in all patient groups. Inappropriate use of enoxaparin was significantly reduced as a result of pathway use in intermediate risk (9% intervention patients vs 75% historical controls vs 45% concurrent controls) and low-risk patients (9% vs 62% vs 41%; P < 0.001 for all comparisons). Pathway use was associated with a 3.5-fold (95% CI: 1.3-9.1; P = 0.012) increase in appropriate use of enoxaparin across all patient groups. CONCLUSION: Active implementation of an acute chest pain pathway combined with continuous education reduced inappropriate use of enoxaparin in patients presenting with intermediate or low-risk ACS.     

Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome

RATIONALE: Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS). OBJECTIVES: To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge. METHODS: We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge. MEASUREMENTS: Clinical and functional outcomes, health care use, and direct medical costs. RESULTS: Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation. CONCLUSIONS: Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.     

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND: The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed. METHODS: A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards. RESULTS: The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients. CONCLUSIONS: A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.     

Effects of care pathways on stroke care practices at regional hospitals

Background: Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. Methods: The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. Results: Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti‐thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). Conclusion: Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.     

Prospective,Randomized, Controlled Trial Between a Pathway of Controlled Rehabilitation With Early Ambulation and Diet and Traditional Postoperative Care After Laparotomy and Intestinal Resection

INTRODUCTION: In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice. METHODS: Sixty-four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol. RESULTS: Pathway patients spent less total time in the hospital after surgery (5.4 vs. 7.1 days; P = 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5 vs. 7.1 days; P = 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P = 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay. CONCLUSIONS: Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome.     

Hospital re-admissions in relation to acute stroke unit care versus conventional care in elderly patients the first year after stroke: the Göteborg 70+ Stroke study

BACKGROUND: re-hospitalisation after discharge following index stroke varies over time and with age and comorbidity. There is little knowledge about whether stroke unit care reduces the need of re-admissions. OBJECTIVES: to examine whether stroke unit care as compared with care in general medical wards was associated with fewer re-hospitalisations for conditions judged to be secondary to acute stroke and to identify the influence of stroke severity on re-admission rates. DESIGN:we conducted a one-year randomised study to compare the outcome of treatment at an acute stroke unit in a care continuum with the outcome of treatment at general medical wards. SETTINGS: acute and geriatric hospitals in G?teborg, Sweden. SUBJECTS: 216 elderly patients aged >or=70 years discharged to their own homes or to institutionalised living after index stroke. METHODS: comparison of comorbidity classified according to Charlson's morbidity index, re-admission rates, length of hospital stay, number of re-admissions and diagnoses between a group treated at a stroke unit and a group treated at general wards. RESULTS: the re-admission rates, length of hospital stay and causes of re-admissions did not differ between the two groups. Complications related to the damage to the brain and concomitant heart disease were the most common causes of re-admissions in both groups. Index stroke severity did not influence the re-admission rates. CONCLUSIONS: re-admissions for conditions judged to be secondary to acute stroke were equal in the two groups in this prospective study.     

Depression and acute myocardial infarction

A number of studies have demonstrated a relationship between depression and low perceived social support and increased cardiac morbidity and mortality in patients with coronary heart disease. There is also evidence that depression increases the risk of acute myocardial infarction and morbidity and mortality following it. This review examines those studies that have investigated these relationships as well as those that have attempted to explain them on the basis of various pathophysiologic mechanisms. Among the latter are studies that have shown that selective serotonin reuptake inhibitors are beneficial in the treatment of depression and that they appear to reverse the enhanced platelet activity observed in depressed patients with acute myocardial infarction. Depression increases hospital length of stay, procedures, readmission rates, and the cost of medical care. Much remains to be elucidated concerning the roles of depression and low perceived social support in predisposing to acute myocardial infarction and to increased morbidity and mortality following it. However, sufficient scientific evidence exists for physicians to make efforts to diagnose and treat depression to reduce the concurrent risk of acute myocardial infarction and morbidity and mortality following it.     

A cost analysis of the first year after stroke - early triage and inpatient rehabilitation may reduce long term costs

AIM OF THE STUDY: To analyse the costs of stroke in the first year covered by insurance companies and to correlate them with the clinical outcome data. METHODS: We contacted the insurance companies of 172 consecutive stroke patients of a single institution cohort for a detailed report of the stroke costs. A complete data set over one year was obtained from 131 patients (76%). RESULTS: Severity of stroke was significantly associated with increasing total costs (p = 0.0002). The rehabilitation clinic made up 37% of the total costs followed by nursing home with 21% and acute hospital with 21%. Mean cost of stroke per patient was 31,115 CHF in the first year. Costs per patient for inpatient rehabilitation were similar to those for the nursing home after one year; however, the Barthel-index of patients with inpatient rehabilitation increased by 42 +/- 29 points as compared to patients without inpatient rehabilitation by 23 +/- 26 points (p <0.05), and 86% resp. 81% of patients with inpatient stroke rehabilitation lived independently after 6 and 12 months respectively. CONCLUSIONS: The high level of independence after inpatient stroke rehabilitation underlines the importance of patient selection and/or rehabilitation. Therefore, long-term stroke costs may be significantly reduced by an early and careful triage in the case management after stroke and a case-dependent investment in initial costly appearing inpatient rehabilitation.     

加速康复外科治疗手术切除肝癌患者的价值探讨

目的比较加速康复外科与传统围手术期处理肝癌切除术患者的安全性及有效性。方法采用加速康复外科治疗23例原发性肝癌切除术病人,采用传统方法进行围手术期处理30例原发性肝癌病人,比较两组病人术后住院时间、肠道恢复排气时间、肝脏功能变化和住院费用情况。结果两组患者术后肛门开始排气时间、首次排便时间比较,差异有显著意义(P0.05);加速康复外科治疗患者较传统治疗住院时间缩短、住院费用降低(P0.05);两组病人术后第3天和第5天谷丙转氨酶、总胆红素、血清白蛋白和前白蛋白水平有显著性差异(P0.05)。结论行加速康复外科治疗肝癌切除术患者是安全、有效的方法,既有利病人术后器官功能的康复,又可以减少住院时间与治疗费用。     

Cost minimization in endoscopy center scheduling: a case-controlled study

BACKGROUND: Traditional endoscopy center scheduling often results in nonurgent inpatient endoscopic procedures being delayed until late in the day and can prolong length of hospital stay and costs. We report the first controlled study designed to evaluate the effect of an early morning fast-track triage endoscopy unit on the cost and length of stay of a general GI inpatient population. METHODS: A case-control methodology matched a cohort of patients undergoing morning triage procedures with historical controls that underwent standard add-on scheduling endoscopy. Outcome indices and patient quality of care measures were compared between cases and controls. RESULTS: Analysis of patients most likely to benefit from rapid endoscopy showed significant advantage comparing fast-track endoscopy patients to controls in time to endoscopy (0.63 vs. 1.00 days, P = 0.01), length of stay (1.22 vs. 1.78 days, P = 0.05), and hospital costs (2,793 dollars vs. 3,586 dollars, P = 0.02). CONCLUSIONS: When routine endoscopy is the rate-limiting step for hospital discharge in the general GI patient, early morning scheduling with a reserved time and space for inpatient endoscopy is a cost-minimizing factor in a busy endoscopy center that may save significant hospital costs while preserving optimal patient outcomes.     

Impact of a clinical pathway for total knee arthroplasty

The purpose of this study is to evaluate the effect of a clinical pathway for total knee arthroplasty in terms of length of stay, hospital costs, and quality of care. One hundred and twenty-two patients who underwent primary total knee arthroplasty for degenerative osteoarthritis in Kaohsiung Medical University hospital were included in the study. The pre-clinical pathway group included 53 patients before clinical pathway implementation (October 1996 approximately September 1997). The clinical pathway group included 69 patients after implementation of the clinical pathway (October 1997 approximately September 1998). All patients were followed up for at least 2 years after surgery. Data collection, including length of stay, hospital costs, comorbidity, and complications, was done by chart review, and Knee Society Clinical Rating System scores were used for assessment of preoperative and postoperative knee function for each group. Statistical analysis included Student's t-test to test the impact of the clinical pathway on resource consumption and medical care processes, and multiple linear regression to control for characteristics such as age and comorbidity. The implementation of the clinical pathway reduced the length of stay by 24%. Hospital costs were reduced by 16%. The implementation of the clinical pathway also reduced the number of unnecessary medical procedures. There was no statistically significant difference between the preoperative or the postoperative knee scores of the pre-clinical pathway group and clinical pathway group. The application of clinical pathway did not affect clinical outcomes and complication rates. In conclusion, the clinical pathway is an effective medical management tool to decrease the length of stay, decrease resource consumption and control medical care expenditure, and this is accomplished without a long-term adverse effect on quality of care.