A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

Abstract

BackgroundClinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke.MethodsThis was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates.ResultsCompared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm.ConclusionsCPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work.Trial registrationClinicalTrials.gov ID: [NCT00673491].

Better Interprofessional Teamwork, Higher Level of Organized Care, and Lower Risk of Burnout in Acute Health Care Teams Using Care Pathways

“…The use of CPs supports health care teams in implementing evidence-based key interventions (KIs) and reduces clinical variations. [17][18][19] Care processes that are supported by CPs are better coordinated and monitored, 20 show better documentation of care and professional practice, 21 and lead to better health services utilization. 22,23 CPs have been defined as high-performance work systems that improve organizational performance by strengthening relationships and coordination among team members.…”

Enrollment volume effect on risk factor control and outcomes in the SAMMPRIS trial

“…For example, stroke order sets and standardized protocols at primary and comprehensive stroke center hospitals boost performance on quality metrics. 12 Performance feedback programs with ongoing education and training are shown to improve risk factor control. Much of the risk factor management in SAMMPRIS was performed by study coordinators using medication titration algorithms with neurologist oversight, mirroring lipid management clinics that use physician extenders commonly seen in clinical practice.…”

Defensive medicine in Italy a nationwide survey

“…In fact, guidelines and related methods like clinical pathways still represent a generalisation of empirical evidence that may not always be applicable to individual patients and/or adopted by legislators [8,10]. These data must be taken as a lesson to learn for the future development of clinical guidelines and clinical pathways [9,22,29].…”