Clinical Pathways in 17 European Union Countries: A Purposive Survey

Article excerpt

Abstract

We undertook a survey of clinical pathways across the 25 European Union countries. Fifty-one questionnaires were completed by largely self-selected experts from 17 countries. Respondents reported that pathways were important and were becoming increasingly widely used (although the rate of progress was highly variable). One important constraint was reported to be a cultural aversion among doctors that arises at least in part from the implication that pathways require multidisciplinary teamwork which will prejudice medical autonomy. In other words, pathways challenge clinical professional sub-cultures. Other constraints included lack of encouragement by external parties, such as purchasers, with limited financial support for pathway development and implementation and service purchasing that did not reward care providers who use pathways.

The obvious implication of the survey is that more needs to be done to achieve a common understanding of pathways. In spite of the large quantity of published papers, survey respondents reported that there are many health professionals who have only a superficial understanding at best.

Aust Health Rev 2005: 29(1): 94-104

Clinical pathways

WE WERE ASKED BY THE European Union (EU) Health Property Network and the Netherlands Board of Health Policy to explore current attitudes and practices with regard to clinical pathways in EU countries. The main aim was to provide one input to assessing the opportunities for future collaboration in the use of clinical pathways in strategic asset planning (SAP). We defined a clinical pathway to be a document that both describes the usual way of providing multidisciplinary clinical care for a particular type of patient and serves as a place to record care actually provided during an episode of care. It allows deviations from the usual method to be recorded, for the purpose of continuous evaluation and improvement of the methods of care. We noted that, although pathways have thus far been used mainly in acute inpatient settings and especially for scheduled surgery, they appear to be equally useful in other care settings. Moreover, they can be used to promote care coordination for patients who need care in multiple settings over prolonged penods of time. This paper focuses on the first part of the study, reporting on the use of clinical pathways.

We conducted a literature review at the start of the study and found that there were increasing numbers of papers that described methods and outcomes. Efficiency gains have been widely reported. For example, Kwan-Gett et al. studied the effects of introducing a clinical pathway for inpatient care of children with asthma and found a 33% reduction in the costs of pathology tests and a 42% reduction in radiology costs.1 Board and Caplan described a decline of 70% in the number of pathology tests from scheduled surgical patients, and of 25% for urgent medical cases.2 Calligaro et al. introduced pathways for vascular surgery and reported that the average length of stay declined from 8.8 to 3.8 days.3 Borkowski reported reductions of 50% in the lengths of stay for elective hip and knee replacements.4

There are similar quantities of literature reporting improved quality of care and outcomes. For example, Chang and Lin analysed the effects of a pathway for laparoscopically assisted vaginal hysterectomy.5 They found that the average operation time decreased by 25% and the average anaesthesia time decreased by 22%. The complication rate was unchanged, but the rate of initiating intravenous antibiotic injections more than 48 hours after surgery decreased by 76%.

Kelly et al studied the effects of using a clinical pathway for hospitalised asthmatic children.6 They found that patients treated using pathways were significantly more likely to complete asthma management training while hospitalised, to be discharged with a prescription for a controller medication, and to have a peak flow meter and a spacer device for home use. …