INTRODUCTION

The demand for the healthcare system to deliver high quality services whilst con­taining expenditure, has forced health ser­vice providers to examine and re­structure the clinical management sys­tems. There is a need for healthcare or­ganizations to per­sistently examine pa­tient care processes, deliver superior quality care, achieve posi­tive clinical and better financial outcomes (Coffey et al. 1992, Pearson et al. 1995, Jones et al. 1999).

The focus of health services has shifted towards controlled clinical management strategies to make healthcare organiza­tions more efficient without compromising the quality of care delivered. There are increasing demands for more appropri­ate use of technologies, more coordi­nated care and more enhanced care given to the pa­tient. Qualities of care and cost contain­ment are debatable and are the foremost and principal agenda on the policy in many countries today (Cheah 2000).

The Ministry of Health, Malaysia has im­plemented several quality assurance pro­grams in government hospitals such as peri-operative morbidity review (POMR), clinical audit, risk management and inci­dent reporting (Ministry of Health Malay­sia 1998). All these programs are very impor­tant to maintain the quality of healthcare in government hospitals.

Clinical pathway has been introduced in many hospitals and has been accepted as a beneficial tool. The CP assists the healthcare organization in providing bet­ter quality and coordinating services within scarce resources (Dowsey et al. 1999, Hoffart & Kuckelman 2000, Kohn et al. 2000, Every et al. 2000). Clinical pathway differs from clinical guidelines, protocol and algorithms. Clinical guide­lines are consen­sus statements that are systematically de­veloped to assist practi­tioners in making patient management decisions related to specific clinical cir­cumstances (Field & Lohr 1990, Dwyer 1998, Gaddis et al. 2007). Protocols are treatments that were recommended based on guidelines.

What is clinical pathway? Clinical path­way is a methodology for mutual decision making, and is an organization of care for a well-defined group of patients during a well-defined period. (European Pathway Association, Slovenia Board Meeting, Dec 2005). The pathway can also be de­fined as a multidisciplinary plan of care based on best clinical practice for specific groups of patients with a particular diag­nosis designed to minimize delays, opti­mise resource utilization and to maximize the quality of care (Pearson et al. 1995, Campbell et al. 1998, Panella et al. 2003). The aim of a care pathway is to enhance the quality of care and cost control by im­proving patient outcomes, promoting pa­tient safety, increasing pa­tient satisfaction, and optimising the use of resources(European Pathway Association, Slovenia Board Meeting, Dec 2005).

Clinical pathway is also known as criti­cal pathway, care map or integrated care pathway. It forms all or part of the clinical record, document the care given and faci­litates the evaluation of outcomes for conti­nuous quality improvement. The CP was developed by multi-professional teams, consist of physicians (family prac­titioners to specialist), nurses, physiothe­rapist, phar­macist, social workers and managers (Pearson et al. 1995, Gregor et al. 1996, Mabrey et al. 1997, Campbell et al. 1998, Healy et al. 1998, Hill 1998, Pritts et al. 1999, Cheah 2000, Huerta et al. 2001, Pearson et al. 2001, Uchiyama et al. 2002, Panella et al. 2003, Lee & Anderson 2006). The pathway was able to facilitate the use of clinical practice guidelines by the multi­disciplinary team, as pathway was locally agreed and avail­able in the patients’ record (Kitcher & Bundred 1998). 

The CP was first developed in the 1950s to coordinate multiple contractors or per­sons in a project by identifying the key se­quence of events or critical point which would drive the timeline of the overall project (Pearson et al. 1995). In healthcare system the CP was first de­veloped and applied in the 1980s at the New England Medical center by Karen Zander and Kathlen Bower (Pearson et al. 1995). The development of CP was in response to the initial Diagnostic Related Group (DRG) based reimbursement system (Pearson et al. 1995, Luttman 2000). The CPs were introduced in the early 1990s in the United Kingdom and the United State of America (Kitcher & Bundred 1998, Lutman 2000)

The implementation of CP is highlighted in the current health care sector because of its similarity to the descriptions of case-mix system which addresses the same clinical characteristics and re­sources involved (Cheah 2000). The de­velopment and im­plementation of CP can be applied in ho­mogenous population, high volume cases, high risk cases and common cases. The CP can also be ap­plied in clinical protocols and guidelines, by committed and account­able health­care providers, health managers and government. The aim of this article was to highlight the benefits of CP in im­prov­ing healthcare quality and cost control.

MATERIALS AND METHODS

For selection of relevant articles, the search was focused on the terms ‘clinical pathway’, ‘care path’ and integrated care pathway. Most studies were conducted in the United States, Canada, Australia and United Kingdom. Only few studies were conducted in Asia.

RESULTS

What can be measured from clinical pathway?

Continuous evaluation and follow up are essential to establish a good CP. The ef­fect of clinical pathway can be measured in five domains; clinical outcome, service, team, process and finance (Herck et al. 2004).The indicators for clinical outcome domain are number of readmissions, com­plications, mortality, number of re­lapses without admission, time until extu­bation, time until normal food intake, quality of life, number of infections, level of pain and length of stay (Kucenic & Meyers 2000, Johnson et al. 2000, Huerta 2001, Benson et al. 2001, Darer et al. 2002, Hoffart & Kuckelman 2002, Kinsman 2004).

For process domain, the indicators are analysis of variance, number of clinical ex­aminations (laboratories, radiology), com­pleteness and quality of documenta­tion, time schedules , planning and ana­lysis of process flow (Johnson et al. 2000, Kucenic & Meyers 2000, Huerta 2001, Benson et al. 2001, Hoffart & Kuckelman 2002, Darer et al. 2002, Kinsman 2004).

The indicators for team domain are team communication, team satisfaction, know­ledge and competence, recognition and appreciation of roles, autonomy of physi­cian, self confidence and influence on un­derstanding (Johnson et al. 2000, Hoffart & Kuckelman 2002, Kinsman 2004).

For financial domain the indicators are length of stay, medical, consumption of resources and number of staff .( Kucenic & Meyers 2000, Kelly 2000, Johnson et al. 2000, Benson et al. 2001, Huerta 2001, Hoffart & Kuckelman 2002, Darer et al. 2002, Kinsman 2004). Finally, the service indicators are patient and family satisfac­tion (Hoffart & Kuckelman 2002, Darer et al. 2002).

Herck et al. (2004) evaluated the effect of the implementation of the clinical pathways and found that the majority of the articles reviewed between years 2000 to 2002 had positive effects on three do­mains namely process, team and finan­cial domain (Table 1).

Benefits of clinical pathway

The majority of literature reviewed con­cluded that there were positive effects in implementing CP. According to more than 80% of the authors, the CP is found to be significant in reducing length of stay and medical cost. The articles include man­agement in patient asthma in pae­diatric cases (Banasiak & Oliver 2004, Cheney et al. 2005), management on uncomplicated acute myocardial infarc­tion (Nichol 1997, Cheah 2000, Kucenic & Meyers 2000, Bahit et al. 2002, Zevola et al. 2002, Lee & Anderson 2006), man­agement of conges­tive cardiac failure (Hogkin 2001, Ranjan et al. 2003), man­agement of pneumonia (Estrada et al. 2000, Loeb et al. 2006) and management of nephrology cases (Benson et al. 2001).The CP is also useful in man­aging surgical cases such as knee joint man­agement (Gregor et al. 1996, Macario et al. 1998, Dowsey et al. 1999, Pearson et al. 2001, Panella et al. 2003, Pennington et al. 2003, Brunenberg et al. 2005, Walter 2005, Xu et al. (2008),manage­ment frac­ture neck of femur (Choong et al. 2000), management of bowel resec­tion (Pritts et al. 1997), laparoscopic sur­gery (Huerta et al. 2001, Uchiyama 2002) fluid manage­ment in femoral neck frac­ture (Davidson 2007) and patients who had undergone total laryngectomy (Hanna et al. 1999).

Standardized processes and better coor­dination in CP have improved patient care among clinicians and managers (Pearson et al. 1995, Gregor et al. 1996, Mabrey et al. 1997, Healy et al. 1998, Pritts et al. 1999, Cheah 2000, Huerta et al. 2001, Pearson et al. 2001, Uchiyama et al. 2002, Panella et al. 2003, Lee & Anderson 2006). The CP also improved clinical outcomes through the variance management system (Luttman 2000, Santoso et al. 2002).

The CP was able to maximize the effi­cient use of resources in reducing unne­cessary documentation (Pearson et al. 1995, Kucenic & Meyers 2000, Kelly 2000, Johnson et al. 2000, Benson et al. 2001, Huerta 2001, Hoffart & Kuckelman 2002, Darer et al. 2002, Kinsman 2004). Most of the articles concluded that one of the measures to control costs and to as­sure quality is the use of a case-ma­naged CP model. The authors also re­vealed CP is useful for costing services (pricing and contracting) (Field & Lohr 1990, Gregor et al. 1996, Healy 1998, Luttman 2000, Huerta et al. 2001)

According to Zander et al. (1988), the major reasons for developing CP are to improve patient care by improving the quality of patient care through consistent management, identifying and measuring improvements in patient care, and mea­suring outcome. The CP has also im­proved communication and collaboration among all disciplines, enhanced the dis­charge coor­dination process and estab­lished protocols to all members of the health care team. CP also can be used to support clinical audit and risk manage­ment (Zander et al. 1988, Dowsey et al. 1999, Cheah 2000, Benson et al. 2001, Darer et al. 2002, Panella et al. 2003, Xu et al. 2008)

In the articles reviewed, only a few stu­dies were conducted in an Asia health care setting. In Singapore, a study con­ducted by Cheah (2000) at a General Hospital dis­covered the average length of stay for un­complicated acute myocardial infarction using CP was significantly re­duced. There was no significant increase in hospital mortality, complication rate and no read­mission rate at six months after discharge. He concluded that CP was able to improve care processes through better collaboration among healthcare professionals and im­proved work systems (Cheah 2000). Santoso et al. (2002) had developed a mastectomy clinical pathway for breast cancer pa­tients at the National University Hospital of Singapore and the results showed that the implementation of the CP had im­proved patients’ treatment and out­come. The medical cost and length of hos­pital stay also was reduced. Similar finding by Xu et al. (2008) shown that the use of knee pathway had led to a significant de­crease in the length of stay, complication rates and early mobilization among 1663 patients who underwent total knee re­placement (tkr) in a tertiary institution in Singapore.

In Taiwan, a study carried out by Liao et al. (1998) at Tsu Chi General Hospital found that CP was able to decrease re­source consumption, control medical ex­penditure and decrease the number of pro­cedures performed. They also demon­strated no changes in clinical outcomes and complication rates in patients who un­derwent transurethral resection of the prostate. In another study conducted by Chang & Lin (2003) they also found the implementation of the CP for patients who underwent vaginal hysterectomy had im­proved health care outcomes, de­creased length of hospital stay and ad­mission fees. The authors concluded that CP is a good policy for cost management and in en­hancing the quality of care.

Paiboon (2006) in his study conducted at Taksin Hospital in Thailand also found the implementation of clinical pathway among type 2 diabetic patients had re­duced the length of hospital stay and de­creased readmission rate of recurrent hypoglycae­mia.

Many studies on CP have been carried out in United States (US) and United Kingdom (UK) (Wigfield & Boon 1996, Chang et al. 2006). The implementation of CP was reported to be high in US and UK with the apparent outcomes such as re­duction in the incidence of complica­tions, medical cost and improved patient satis­faction (Chang et al. 2006 and Wigfield & Boon 1996).

Ranjan et al. (2003) had carried out a study among congestive heart failure (CHF) patients at hospitals in United States and the result showed that the patients as­signed to the CHF CP had a shorter length of stay and reduced hos­pital charges com­pared with those who were on the usual care. The quality of care delivered (as measured by adminis­tration of ACE inhibi­tors) was not com­promised by the reduc­tion in length of hospital stay in patients on the clinical pathway. Further there was a significant saving of US2,500 per patient and US750,000 per year in CHF treatment (Ranjan et al. 2003) 

A study conducted by Pearson et al. (2001) also found with the implementa­tion of the CP, the length of stay de­creased 21% for total knee replacement, 9 % for CABG surgery, 7% for thoracic surgery, 5% for hysterectomy and 3% for colect­omy. In 1999, Pritts et al. con­ducted a study at University of Cincinnati Medical Center, Ohio and showed a sig­nificant de­crease in length of stay and medical cost in the pathway groups who underwent bowel resection.

Several studies also found improve­ment of interdisciplinary cooperation, staff satis­faction (Mabrey et al. 1997, Maxey 1997, Hanna et al. 1999, Jacavone et al. 1999)and also patient satisfaction (Jacavone et al. 1999, Walter 2005).

About 40.0% of the authors discovered the clinical outcomes such as readmis­sion, mortality and complication rates showed no significant difference between patients on clinical pathway and patients on usual care (Nichol et al. 1997, Macario et al. 1998, Jones et al. 1999, Choong et al. 2000, Farquhar 2000, Johnson et al. 2000, Kucenic & Meyer 2000, Hogkin et al. 2001, Huerta et al. 2001, Uchiyama et al. 2002, Ranjan et al. 2003, Banasik & Oliver 2004, Brunenberg et al. 2005, Lee & Anderson 2006). Nevertheless, one third of the au­thors found the readmission and compli­ca­tion rates were reduced in the clinical pathway group and there was significant difference compared to the non clinical pathway group (Dowsey et al. 1999, Estrada et al. 2000, Cheah 2000, Benson et al. 2001, Bahit et al. 2002, Darer et al. 2002, Ransom et al. 2002, Panella et al. 2003, Bestul et al. 2004, Cheney et al. 2005, Walter et al. 2005, Loeb et al. 2006, Paiboon 2006, Xu et al. 2008).

Even though CP has been approved as beneficial tools in improving quality and controlling healthcare cost, there are a few aspects and factors which require attention as revealed by nearly one third of the ar­ticles reviewed (Gregor et al. 1996, Pritts et al. 1997, Macario et al. 1998, Dowsey et al. 1999, Choong et al. 2000, Cheah 2000, Pearson et al. 2001, Hogkin 2001, Uchiyama 2002, Panella et al. 2003, Ranjan et al. 2003, Brunenberg et al. 2005, Walter 2005, Lee & Anderson 2006). The aspects that require attention are the un­derstanding, implementation, accountabil­ity, the system and the ad­ministrative sup­port of the CP.

CONCLUSION

As a conclusion, the majority of literature reviewed concluded that there were posi­tive effects in implementing CP. The CP was not only found to be significant in re­ducing length of stay and medical cost but is also found to support the introduc­tion of evidence based medicine, clinical audit, multi disciplinary communication, teamwork and care planning. In addition, the CP is able to support the continuity and coordi­nation of care across different clinical dis­ciplines, reduce variances in patient care (by promoting standardiza­tion), help im­prove patient documentation and optimize the management of re­sources. Even though CP had been shown to improve quality and control of healthcare costs, its successful imple­mentation would require full commitment andparticipation from all health care pro­viders and healthcare man­agers.