Care Pathways: A Map to Consistent, High-Quality Care
As hospitals and health care systems look for ways to improve patient outcomes while simultaneously cutting costs, one promising opportunity is the use of Care Pathways. Pathways are a workflow document of best practices for patients with specific diseases and conditions, designed to ensure patients receive consistent, high-quality care.
According to Scott Livingstone, chief operating officer (COO) of Tri-City Medical Center, Care Pathways are evidence-based, coordinated care protocols that implement standardized best practices. One notable example of Care Pathways is the Perioperative Surgical Home (PSH)—a model of care developed by leaders within the American Society of Anesthesiologists. Tri-City uses a PSH for colorectal elective surgery cases. The process begins as soon as the surgeon schedules the procedures and continues until 30 days after the patient is discharged.
“This process enables the patient to better withstand the procedure,” said Livingstone. The result is a reduction in the average length of stay (LOS) of one to one-and-a-half days, a decreased infection rate, and a drastic reduction in opioids for pain management after the procedure.
The use of Pathways within hospitals is an extension of the quality and cost-saving initiatives manufacturers began using decades ago, referred to as industrial quality management. The objective is to create standard operating procedures (SOPs), with the primary goals being quality and the efficient use of resources. The health care version of SOPs, Care Pathways, or Clinical Care Paths, were first introduced in the 1980s by Karen Zander and Kathleen Bower at the New England Medical Center.
But are they effective? In a study by Seattle Children’s Hospital (SCH), Pathways were implemented for a range of pediatric conditions with the goal of improving patient outcomes, decreasing costs, and reducing LOS and readmissions. The results revealed that both patient costs and LOS trended downward after Pathways were implemented (Figure 1). Overall, the study found that post-Pathway care was associated with a significant halt in rising costs, and “significantly decreased LOS without negatively impacting patient physical functioning improvement or readmissions.”
Extending Care Across Facilities
Pathways provide the opportunity for synergy across multiple facilities and solidify a consistent approach to patient care. Hospitals are accountable for the patient’s care three days before admission and 30, 60 or 90 days after discharge, whether the patient goes to a skilled nursing facility (SNF) or home with outpatient care.
The cost savings and improved patient outcomes as a result of this synergy can be dramatic. In addition to the results from SCH, The University of Colorado Hospital ED developed over 50 Care Pathways to guide care and use of its resources. The measurable results included:
When Pathways were first introduced, few hospitals implemented them because care-givers found it difficult to track progress, share information and capture data on paper. The advent of electronic health records (EHRs) eliminated that barrier, creating the ability to automate practice guidelines with a way to quickly monitor progress through electronic methods. The emergence of EHRs, combined with the increasing arrival of big data in medicine, has cleared the way for the medical community to be more receptive to evidenced-based medicine in general, and Pathways in particular.
Are Care Pathways Compatible With Precision Medicine?
At first glance, these standardized care protocols may appear to contradict the push toward precision medicine (PM), where treatment is individualized based upon the patient’s genetic make-up. Physicians, even within the same hospital, often vary in their treatment approaches for patients with the same diagnosis.
There is currently a shift toward PM which appears, on the surface, to make Pathways look out-of-date. Breakthroughs in next-generation sequencing and bioinformatics are paving the way for physicians to tailor treatments to a patient’s specific genotype. As such, Pathways may seem to limit the physician’s ability to tailor the treatment around the patient’s genetic make-up. Upon closer look, however, there are critical similarities between the procedures and processes of Pathways and PM. Both rely on identifying the variables involved in the treatment of individual patients and combining that with historical evidence to determine which treatment options are more effective than others. Hospitals rely on this information as they take the time to create individual Pathways to help their patients. These same processes of discovery and best practices are used in PM to ensure treatment options are focused to match a specific patient’s gene with the appropriate treatment protocol. In many ways, PM can be viewed as an enhanced version of Pathways.
Creating Pathways With Best Practices
While physicians understand the importance of following best practices, Pathways cannot dictate medical care. Physicians still must make the decision about what is best for the patient, with the flexibility to tailor the plan as necessary.
The key is to use evidence-based, confirmed-care Pathways and algorithms that are fully standardized. To ensure safety, these Pathways should be vetted by a nationwide quality team of medical professionals and experts.
As Pathways are created, hospitals must ensure that compensation is not linked to the protocol. Physicians will, from time to time, have to deviate from the plan in the interest of the patient. When this happens, the provider should not be penalized.
Going forward, the Pathway protocol may extend to care coordination among long-term care facilities, rehabilitation centers and home care. Further, as both providers and payers utilize Pathways, it is essential that they serve as a resource for clinicians, and not be a restriction on the care a patient receives. Hospitals still must see their patients as individuals and adapt the guidelines to meet their needs. The Pathway should provide the foundation and instructions to care.
Bruce Lorenz, Chair