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PubMed1995

Collaborating to reduce costs in invasive cardiology: the Partners Healthcare experience. Partners Healthcare Invasive Cardiology Team.

BACKGROUND: As part of the closely watched marriage between Brigham and Women's Hospital and Massachusetts General Hospital, the invasive cardiology team--cardiologists and other staff from the two organizations--began with monthly meetings; its mission is to reduce costs of cardiology services while maintaining or improving patient satisfaction and outcomes. IMPROVEMENT EFFORTS: Joint purchasing efforts have led to substantial price reductions for some supplies, such as pacemakers and balloon angioplasty. However, concern over quality drove cardiologists to choose newer, more expensive models of other supplies, such as implantible cardioverter-defibrillators. Also, the team is studying the actual costs savings that can be achieved by shifting patients undergoing cardiac catheterization to the outpatient setting. In addition, cardiologists recognized an opportunity to decrease length of stay and increase quality by removing the arterial sheath for uncomplicated percutaneous transluminal coronary angioplasty patients on the same day the procedure is performed. Each hospital is developing strategies for this change in procedure. In addition to these improvement efforts, the team is encouraging optimal use of contrast agents and increasing overall efficiency of laboratories. Team members are also sharing guidelines and critical pathways and developing strategies for evaluating new technologies. LESSONS LEARNED: The team has had little difficulty in achieving a collegial atmosphere and consensus around clinical issues and products once clinicians are face-to-face. Announcing bimonthly meetings may overcome meeting scheduling difficulties. The other major stumbling block has been the lack of detailed cost information.

Boston↗
PubMed1997

Using partner hospitals in collaborative benchmarking..

In May 1994 the Physiotherapy Department at John Hunter Hospital received a Commonwealth Best Practice in the Health Sector grant to design a critical pathway for the treatment of stroke. The implementation of the pathway at John Hunter Hospital and the introduction of the methodology to secondary sites (The Alfred Healthcare Group, Melbourne, and Royal Hobart & Repatriation General Hospitals, Hobart) resulted in the development of a Benchmarking Consortium. This paper will discuss the importance of benchmarking in understanding clinical processes, and the methodology employed to ensure that meaningful benchmarks were achieved.

Ancillary Services, Hospital↗
PubMed2005

[Should disease management be feared? (1): hospital care].

The goals of disease management are: (1) an integrated health care delivery system; (2) knowledge-based care; (3) elaborate information systems; (4) continuous quality improvement. In-hospital disease management and, more specifically, critical pathways, establish standardized care plans, set goals and time actions to reach these goals. They can reduce variations in practice patterns and resource utilization without compromising quality of care. Such strategies participate to quality improvement programs in hospitals when they involve and empower all actors of a given process of care, are not imposed from outside, and use sound and rigorous development and evaluation methods.

Critical Pathways↗
PubMedDate not supplied

Centers of excellence: a medical measurement or marketing myth?

Managed care organizations, physician groups and hospital systems are all increasingly pressured to identify new modes of treatment that produce verifiable outcomes while reducing the revolving door pattern of health care for the chronically ill. Providers are also faced with creating systems of care to differentiate themselves from the competition in the marketplace. Disease-specific health management programs are being used to address both issues. When used properly, they can be promising tools in the battle to maintain health care quality while containing costs. Skillful balancing of these two important factors can ensure maximum value for both patients and payers. Are centers of excellence the critical pathway of the future? Or are they merely a marketing ploy to generate incremental growth and profitability for savvy business executives and medical group management entrepreneurs? This article provides an overview of the center of excellence concept, addresses its misuse in the industry and discusses the strategic and marketing implications for organizations considering this approach as a tool to demonstrate full accountability and meritorious outcomes.

Case Management↗
PubMed1997

Cancellations cut by three-fourths.

A critical pathway of lumbar discectomy has helped Blodgett Memorial Medical Center in Grand Rapids, MI, decrease cancellations by incorporating a preoperative telephone call one to two weeks before surgery. 50% of patients are going home in 23 hours or less. A handful of those are going home the same day as the procedure. The preoperative telephone call includes registration, education, instruction about laboratory tests to be done before the day of surgery, and even discharge planning.

Critical Pathways↗
PubMed2004

Comparison of presenting features, diagnostic tools, hospital outcomes, and quality of care indicators in older (>65 years) to younger, men to women, and diabetics to nondiabetics with acute chest pain triaged in the emergency department.

In a total of 4,843 consecutive patients admitted to an emergency department (ED) with acute chest pain over a 1-year period, presenting features, diagnostic tools, hospital outcomes, and quality-of-care indicators were compared between older (n = 1,781) and younger (n = 3,062) patients, men (n = 3,095) and women (n = 1,748), and diabetics (n = 856) and nondiabetics (n = 3,987). The results showed that after critical pathway implementation, there was an increase in the use of evidence-based treatment strategies in the ED and improved outcomes in older patients, women, and diabetics, with no more differences in the length of ED stay, diagnostic accuracy for myocardial infarction in the ED, door-to-thrombolysis time, and door-to-balloon time compared with younger patients, men, and nondiabetics.

Aged↗
PubMed2006

Conceptual models used by nurses working in coronary care units--a discussion paper.

In the UK, Europe and the USA conceptual models of nursing are features of many undergraduate nursing curricula [Alligood MR. The nature of knowledge needed for nursing practice. In Alligood MR, Marriner-Tomey A, editors. Nursing theory utilisation and application. London: Mosby, 2002, Tierney AJ. Nursing models extant or extinct? J Adv Nurs 1998;8(1):77-85] and commonly used in practice. However, UK nurses in practice continue to be dissatisfied with conceptual model use [Griffiths P. An investigation into the description of patients' problems by nurses using two different needs-based nursing models. J Adv Nurs 1998;28(5):969-977, Mason C. Guide to practice or 'load of rubbish'? The influence of care plans on nursing practice in five clinical areas in Northern Ireland. J Adv Nurs 1999;29(2):380-387, Murphy K, Cooney A, Casey D, Connor M, O'Connor J., Dineen B. The Roper, Logan and Tierney Model: perceptions and operationalization of the model in psychiatric nursing within one health board in Ireland. J Adv Nurs 2000;31(6):1333-1341]. An association with increased paperwork and documentation together with a belief that these abstract concepts do not quite fit with the practice setting has resulted in a generalised apathy towards their use in some areas [Timmins F. Critical care nursing in the 21st Century. Intensive Crit Care Nurs 2002;18:118-127]. In an era of concerns about both cost and quality, together with an increased impetus towards multi-professional working patterns and role expansion, alternative models of care, such as critical pathways and care pathways are gaining increased favour in the clinical setting [Johnson S, editor. Pathways of care. Oxford; Blackwell Science 1997]. The aim of this paper is to consider whether or not the traditional conceptual models of nursing are apt for today's practicing coronary care nurse. Specific questions to be addressed are: what is the research evidence that informs conceptual model use in coronary care and what are the conceptual models that commonly inform contemporary practice in coronary care nursing? Suggested ways forward for conceptual model use within nursing are also proposed.

Attitude of Health Personnel↗
PubMed1998

Ensuring early discharge following major surgery: orthopedic surgery.

Managed care, critical pathways, and length of stay issues have a major impact on current hospital policy and patient care. In orthopedic surgery, significant strides have been made in improving efficiency, decreasing costs, and reducing length of stay. Use of vertical pathways, especially the first day of admission, the day of surgery, is important for efficient patient care. As anesthesiologists involved in the process, we must be certain that patient care is not compromised in an attempt to save money or achieve early discharge. In many studies, pain management, type of anesthesia, and amount of blood loss are not significant factors in length of hospital stay. These factors must be approached as quality-of-life issues and appropriate decisions made.

Ambulatory Surgical Procedures↗
PubMed1998

Evaluating and improving the delivery of heart care: the University of Michigan experience.

With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.

Cardiology Service, Hospital↗
PubMed1997

Redesigning the care of carotid endarterectomy patients.

Recent studies have supported the effectiveness of carotid endarterectomy (CEA) as a treatment for significant carotid stenosis. While the efficacy of CEA has been established, it is important to review the processes and outcomes of care to ensure high-quality, cost-effective care. As part of a quality-improvement process, our hospital's Vascular Surgery Quality Improvement Team redesigned the care for patients having CEA surgery. Practice changes, implemented in January 1995, included routine discharge on the first postoperative day; a new critical pathway supported by a computerized order set, a switch from general anesthesia to a regional block approach, and the use of an algorithm in treating postoperative hypertension. The impact of these changes on cost and quality were then analyzed. A retrospective chart audit was completed on 185 CEA surgeries performed in 1995. Length of stay decreased by 1.15 days, and costs were reduced by $1900 per case, with no change in postoperative morbidity or mortality rates. The incidence and severity of postoperative hypertension, bradycardia, and hypotension were also analyzed, supporting the practice changes and the current level of nursing care.

Aged↗
PubMedDate not supplied

Opportunities for improving the care of patients with community-acquired pneumonia.

In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia.

Critical Pathways↗
PubMed1996

The JIM Interview. Lee Goldman, MD.

In early 1995, Lee Goldman, MD, left his post as chief medical officer at the Brigham and Women's Hospital in Boston to become the chairman of medicine at the University of California, San Francisco. A well-respected clinical epidemiologist, Goldman has been among the leading proponents of utilizing critical pathways to improve the efficiency of clinical care. His appointment as leader of a department steeped in a strong tradition of basic research was widely seen as another marker in the ascendancy of the field of health services research. However, in just his first year, Goldman has been active in working to further solidify his department's strong basic research foundation as well as expand its research scope, all in what many consider to be the most difficult and volatile of managed care markets. Interviewed on the wards of the UCSF medical center, Goldman reflected on the highly dynamic managed care environment of northern California, and the need to adapt medical training to the rules of a new era in health care.

Critical Pathways↗
PubMed2005

Evidence-based practice: a practical approach to implementation.

Organizations often do not have processes in place to support nurses through a systematic approach for developing and evaluating nursing interventions, protocols, critical pathways, and policies that are derived from scientific evidence. The development of a framework to guide inquiry will have a positive impact on patients. This process may foster a higher level of professional engagement by nurses that may, in the long-term, help improve nurse retention and recruitment. The authors discuss a nursing evidence-based practice model and guidelines that were developed by a team of hospital and academic nurse leaders and is practical and easy to use. This model has been successfully implemented across the department of nursing as a strategic initiative. Results of the implementation have shown that staff nurses can effectively use this model with the help of knowledgeable mentors.

Attitude of Health Personnel↗
PubMed2002

Effect of anti-IL-2Ralpha antibody on IL-2-induced Jak/STAT signaling.

Acute allograft rejection is driven by production of cytokines such as interleukin-2 (IL-2) that activate and expand alloreactive T cells by ligating high-affinity IL-2 receptors composed of three subunit chains: alpha, beta, gamma The alpha chain, expressed only on activated T cells, has become an important therapeutic target. Monoclonal antibodies (mAbs) that bind IL-2Ralpha chains significantly decrease transplant rejection. We examined the ability of the humanized anti-IL-2Ralpha antibody daclizumab to block high-affinity IL-2Rs and interrupt T-lymphocyte signaling. Our evaluation focused on a pathway critical for T-cell proliferation, the Jak/STAT pathway. Daclizumab markedly inhibited phosphorylation of the Jak1, Jak3 and STAT5a/b components of the IL-2R-dependent pathway. Suppression by daclizumab was associated with internalization of IL-2Ralpha but not IL-2Rbetagamma chains. High IL-2 doses overcame daclizumab-induced blockade of Jak/STAT phosphorylation despite absent cell surface highaffinity IL-2Rs. Under these circumstances, IL-2-mediated Jak/STAT pathway activation might be generated through residual intermediate affinity IL-2Rbetagamma receptors, and this was demonstrated by complete blockade of signaling when anti-IL-2Rbeta monoclonal antibody was added. Humanized antibodies are an important part of strategies to induce alloantigen tolerance. Understanding the molecular events associated with their beneficial clinical effect is critical to design of future immunosuppressive strategies.

Antibodies, Monoclonal↗
PubMed2000

Multimodality reperfusion therapy for acute myocardial infarction.

With the strong and direct relation between early reperfusion in acute myocardial infarction (AMI) and improved clinical outcomes, attention has focused on new means of improving rates of reperfusion and accelerating every stage of AMI evaluation and management, from the onset of symptoms of myocardial infarction to the achievement of reperfusion. Critical pathways to streamline the evaluation and management of AMI have cut minutes and even hours off in-hospital treatment times for patients with AMI; public health initiatives focus on educational efforts to shorten time to hospital arrival. The latest advance in fibrinolytic therapy is the availability of bolus fibrinolytic agents with safety and efficacy in large phase III trials comparable to accelerated intravenous infusion regimens. Faster and simpler fibrinolytic regimens may shorten door-to-needle time, reduce medication errors, and facilitate prehospital thrombolysis. Bolus fibrinolytic agents are being evaluated for use in combination with other interventions to open occluded coronary arteries, including acute percutaneous coronary intervention, the glycoprotein IIb/IIIa platelet inhibitors, or both. The goal of this "multimodality" approach to AMI management is to minimize time to reperfusion and maximize the percentage of patients who achieve complete arterial patency and myocardial perfusion without bleeding complications.

Critical Pathways↗
PubMedDate not supplied

The road to developing standards for the diagnosis and treatment of venous leg ulcers.

In early 1996 the Venous Leg Ulcer Guideline was developed for the diagnosis and treatment of venous leg ulcers. In order to discuss the development of standards in general, and the Venous Leg Ulcer Guideline in particular, we first need to understand the difference between the following terms: Critical pathway, consensus statement, guideline, and standard. There are advantages and disadvantages to the use of guidelines. In the development of a guideline, endorsement by a respected colleague is important. Development of the Venous Leg Ulcer Guideline began with a consensus statement and then underwent review by a national advisory panel and national peer review through publication. A revised guideline has now been developed which will be tested in a pilot study for clinical efficacy, effect on cost, and impact on quality of life. Validation will require implementation in a prospective clinical trial. Diagnostic and Treatment Algorithm forms for the diagnosis and treatment of venous leg ulcers were developed as part of the preliminary testing of the guideline. Although guidelines do not substitute for good clinical judgement, they can encourage clinical judgement and help reduce fragmented care and the costs associated with inappropriate treatments.

Critical Pathways↗
PubMedDate not supplied

Designing a system for ambulatory obstetric case management.

The authors describe the development of critical pathways for ambulatory obstetric case management. When case management was identified as needed, but published work in outpatient obstetrics could not be found, four nurses used this opportunity to design a cost-effective system leading to quality outcomes. The driving force was the need for a format that directed comprehensive consistent care delivered by a large multidisciplinary health care team. Design issues included capturing leading edge standards of care and user friendly formats for all caregivers. Throughout a period of 2 years, a trifold format was developed for all obstetric patients, and 15 bifold formats were developed for patients with specific high-risk diagnoses. The format design facilitated cost-effective quality care and is expected to improve patient outcomes. A research study has been initiated to measure effectiveness of the design.

Ambulatory Care↗
PubMed2006

Identifying the impact of diabetes research.

AIMS: Assessment of the impact of health research is a growing but problematic field. We examined how a combination of approaches might together inform assessment of the impact of a body of diabetes research published in 1981 and help identify factors behind success. METHODS: Three broad approaches were applied to the work of one team leader of acknowledged influence. Standard bibliographic analysis was complemented by a second approach which categorized the importance of the primary publications to the papers citing them, in four domains. In parallel, a third approach involved qualitative assessment using surveys, critical pathway analysis by, and interviews of, co-authors and external experts. Extending the approach incorporated key additional publications from other years. RESULTS: In 1981, the team leader published 29 papers. Citations to these 29 first generation papers varied from 1 to 76 and resulted in 799 second generation papers. Citations to these produced 12 891 third generation papers. Analysis of second generation papers suggested the cited first generation paper was thought to be of considerable or essential significance in only 9% of cases. While much research made little impact, qualitative analysis included a wealth of information, sometimes missed by standard bibliographic techniques, on where the identified research influenced important streams of clinical development. Analysis covered major research studies (such as the Diabetes Control and Complications Trial), insulin pump therapy, and career development of co-authors. CONCLUSIONS: Understanding the impact of research requires multiple approaches. With refinement, these techniques could be employed more widely and potentially could inform research policy.

Acarbose↗