Top

Langenbeck's Archives of Surgery

Published in:

01-01-2009 | Original Article

Impact of clinical pathways in surgery

Authors: Markus K. Müller, Konstantin J. Dedes, Daniel Dindo, Stefan Steiner, Dieter Hahnloser, Pierre-Alain Clavien

Published in: Langenbeck's Archives of Surgery | Issue 1/2009

Abstract

Background

One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities.

Method

Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65).

Results

Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from € 6,390 to € 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from € 1,810 to € 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07).

Conclusions

This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Bundesamt für Statistik: Gesundheitskosten in der Schweiz: Bundesamt für Statistik. www.bfs.admin.ch/bfs/portal/de/index/themen/gesundheit.html 2007

Smith C, Cowan C, Heffler S, Catlin A (2006) National health spending in 2004: recent slowdown led by prescription drug spending. Health Aff (Millwood) 25(1):186–196CrossRef

Pfau PR, Cooper GS, Carlson MD, Chak A, Sivak MV Jr, Gonet JA et al (2004) Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding. Am J Gastroenterol 99(3):425–431PubMedCrossRef

Buckmaster ND, Heazlewood V, Scott IA, Jones M, Haerer W, Hillier K (2006) Using a clinical pathway and education to reduce inappropriate prescribing of enoxaparin in patients with acute coronary syndromes: a controlled study. Intern Med J 36(1):12–18PubMedCrossRef

Lemberg DA, Day AS, Brydon M (2005) The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis. Am J Med Qual 20(2):83–89PubMedCrossRef

Archer SB, Burnett RJ, Flesch LV, Hobler SC, Bower RH, Nussbaum MS et al (1997) Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis. Surgery 122(4):699–703, discussion 703–705PubMedCrossRef

Pritts TA, Nussbaum MS, Flesch LV, Fegelman EJ, Parikh AA, Fischer JE (1999) Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 230(5):728–733PubMedCrossRef

Porter GA, Pisters PW, Mansyur C, Bisanz A, Reyna K, Stanford P et al (2000) Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 7(7):484–489PubMedCrossRef

Melbert RB, Kimmins MH, Isler JT, Billingham RP, Lawton D, Salvadalena G et al (2002) Use of a critical pathway for colon resections. J Gastrointest Surg 6(5):745–752PubMedCrossRef

10.

Huerta S, Heber D, Sawicki MP, Liu CD, Arthur D, Alexander P et al (2001) Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center. Am Surg 67(12):1128–1135PubMed

11.

Soria V, Pellicer E, Flores B, Carrasco M, Candel Maria F, Aguayo JL (2005) Evaluation of the clinical pathway for laparoscopic cholecystectomy. Am Surg 71(1):40–45PubMed

12.

Tan JJ, Foo AY, Cheong DM (2005) Colorectal clinical pathways: a method of improving clinical outcome. Asian J Surg 28(4):252–256PubMed

13.

Murphy MA, Richards T, Atkinson C, Perkins J, Hands LJ (2007) Fast track open aortic surgery: reduced post operative stay with a goal directed pathway. Eur J Vasc Endovasc Surg 34(3):274–278PubMedCrossRef

14.

Kennedy EP, Rosato EL, Sauter PK, Rosenberg LM, Doria C, Marino IR et al (2007) Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution—the first step in multidisciplinary team building. J Am Coll Surg 204(5):917–923, discussion 923–924PubMedCrossRef

15.

Kariv Y, Delaney CP, Senagore AJ, Manilich EA, Hammel JP, Church JM et al (2007) Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum 50(2):137–146PubMedCrossRef

16.

Ronellenfitsch U, Rossner E, Jakob J, Post S, Hohenberger P, Schwarzbach M (2008) Clinical Pathways in surgery—should we introduce them into clinical routine? A review article. Langenbecks Arch Surg 393(4):449–457PubMedCrossRef

17.

El Baz N, Middel B, van Dijk JP, Oosterhof A, Boonstra PW, Reijneveld SA (2007) Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research. J Eval Clin Pract 13(6):920–929PubMed

18.

Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedCrossRef

19.

Woolhandler S, Campbell T, Himmelstein DU (2003) Costs of health care administration in the United States and Canada. N Engl J Med 349(8):768–775PubMedCrossRef

20.

Berk PD (1993) Restructuring American health care financing: first of all, do no harm. Hepatology 18(1):206–215PubMedCrossRef

21.

Wilson G (1997) A dilemma—public health care. Gesundheitswesen 59(2):117–122PubMed

22.

Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S et al (2001) Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 233(5):704–715PubMedCrossRef

23.

Cooney RN, Bryant P, Haluck R, Rodgers M, Lowery M (2001) The impact of a clinical pathway for gastric bypass surgery on resource utilization. J Surg Res 98(2):97–101PubMedCrossRef

24.

Uchiyama K, Takifuji K, Tani M, Onishi H, Yamaue H (2002) Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery. Surg Endosc 16(11):1594–1597PubMedCrossRef

25.

Hampton DC (1993) Implementing a managed care framework through care maps. J Nurs Adm 23(5):21–27PubMed

26.

Ellis BW, Johnson S (1999) The care pathway: a tool to enhance clinical governance. Clin Perform Qual Health Care 7(3):134–144PubMedCrossRef

27.

Riley K (1998) Care pathways. Paving the way. Health Serv J 108(5597):30–31PubMed

28.

(1997) Lap choly pathway leads to efficiency, savings. Hosp Case Manag 5(7):125–128

29.

Herzlinger RE, Parsa-Parsi R (2004) Consumer-driven health care: lessons from Switzerland. JAMA 292(10):1213–1220PubMedCrossRef

30.

Clavien PA, Sanabria JR, Strasberg SM (1992) Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 111(5):518–526PubMed

31.

American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2002) Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 96(2):485–496CrossRef

32.

Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE et al (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 39(3):542–553PubMedCrossRef

33.

Antioch K, Chapman R, Elliott B, Santamaria N, Crawford R, Fiddes K (2001) Cost-effective clinical pathways at the Alfred Hospital: international lessons from Bayside Health, Australia. Aust Health Rev 24(4):21–29PubMedCrossRef

34.

Kinsman L, James E, Ham J (2004) An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage. Lippincotts Case Manag 9(4):184–196PubMedCrossRef

35.

Allen JW, Hahm TX, Polk HC Jr (2003) Surgeon-led initiatives cut costs and enhance the quality of endoscopic and laparoscopic procedures. JSLS 7(3):243–247PubMed

36.

Warner BW, Rich KA, Atherton H, Andersen CL, Kotagal UR (2002) The sustained impact of an evidenced-based clinical pathway for acute appendicitis. Semin Pediatr Surg 11(1):29–35PubMedCrossRef

37.

Ferri LE, Feldman LS, Stanbridge DD, Fried GM (2006) Patient perception of a clinical pathway for laparoscopic foregut surgery. J Gastrointest Surg 10(6):878–882PubMedCrossRef

38.

Dy SM, Garg PP, Nyberg D, Dawson PB, Pronovost PJ, Morlock L et al (2003) Are critical pathways effective for reducing postoperative length of stay. Med Care 41(5):637–648PubMedCrossRef

39.

Vanounou T, Pratt W, Fischer JE, Vollmer CM Jr, Callery MP (2007) Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 204(4):570–579PubMedCrossRef

Title: Impact of clinical pathways in surgery
Authors: Markus K. Müller
Konstantin J. Dedes
Daniel Dindo
Stefan Steiner
Dieter Hahnloser
Pierre-Alain Clavien
Publication date: 01-01-2009
Publisher: Springer-Verlag
Published in: Langenbeck's Archives of Surgery / Issue 1/2009
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-008-0352-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Impact of clinical pathways in surgery

Abstract

Background

Method

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Method

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2009

Treatment with keratinocyte growth factor does not improve lung allograft survival in the rat

Food fight! Parenteral nutrition, enteral stimulation and gut-derived mucosal immunity

Interleukin-2 immunotherapy action on innate immunity cells in peripheral blood and tumoral tissue of pancreatic adenocarcinoma patients

Occult disseminated tumor cells in lymph nodes of patients with gastric carcinoma. A critical appraisal of assessment and relevance

Hypothermic in situ perfusion of the porcine liver using Celsior or Ringer-lactate solution

Effect of surgical work volume on postoperative complication: superiority of specialized center in gastric cancer treatment