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PubMed2005

Diagnostic imaging pathways: development, dissemination, implementation, and evaluation.

ISSUE: There are signs of inappropriate application of medical imaging to diagnosis. Inappropriate imaging is a threat to effective diagnosis and effective allocation of resources. The development and deployment of knowledge-based clinical decision support systems is one strategy to reduce inappropriate imaging. DEVELOPMENT OF IMAGING PATHWAYS: A suite of 78 imaging pathways was conceived both as a decision support and educational tool. The pathways were drafted by imaging specialists, but further developed and modified, based on graded evidence and input from requesting clinicians. An electronic environment was developed to contain and deliver the pathways. DISSEMINATION AND IMPLEMENTATION: Imaging pathways were distributed via a hospital local area network and on compact disk. A multifaceted approach was used to raise general awareness of the pathways, followed by intensive 'marketing' activities. Two groups of clinicians were targeted; hospital-based clinicians and general practitioners. EVALUATION: There was increased awareness of imaging pathways. Clinicians judged them to be useful for education and decision support. The method of electronic delivery was adequate. Knowledge of diagnostic imaging and requesting behaviour tended to become more aligned with the pathways. The central objective to reduce inappropriate medical imaging seems to be achievable. LESSONS LEARNED: There is scope to improve the content and the electronic environment, achieve better integration into decision-making processes, and achieve better compliance. A linkage between imaging pathways and electronic requesting could provide alerts to 'non-compliant' requesting. The assignment of a higher cost, or a lower remuneration, to non-authorized and non-compliant imaging would provide tangible incentive to comply, unless there are compelling clinical contraindications.

Attitude of Health Personnel↗
PubMed2001

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Academic Medical Centers↗
PubMed1998

Effect of a clinical pathway for severe traumatic brain injury on resource utilization.

BACKGROUND: The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization. METHODS: A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded. RESULTS: The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes. CONCLUSION: The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma.

Adult↗
PubMed2007

Success of clinical pathways for total joint arthroplasty in a community hospital.

Clinical pathways for total joint arthroplasty have been implemented successfully during the past decade. We report the results of pathway use for primary elective total hip and total knee arthroplasty in a community teaching hospital. We evaluated pathway efficacy using patient data forms and the hospital's financial database. Before instituting the pathway, the average length of stay was 4.41 days for patients having total hip arthroplasty and 3.92 days for patients having total knee arthroplasty. The average length of stay for patients having total hip arthroplasty decreased to 3.24 days and to 2.98 days for patients having total knee arthroplasty. Press Ganey Survey results showed high patient satisfaction rates before and after pathway initiation. Pathway implementation did not lead to increased complication rates or readmissions. Despite higher expected increases in the overall healthcare cost during the time of implementation (3 years), direct cost increases were limited to 3.48%. The key elements contributing to pathway success included preoperative patient education, standardized orders derived from evidence-based medicine, and a nurse practitioner who championed the pathway and ensured compliance. We recommend clinical pathways for patients having total joint arthroplasties to reduce length of stay, facilitate effective resource use, and preserve quality of care without compromising patient satisfaction or safety.

Aged↗
PubMed1996

Integrated care pathways: effective tools for continuous evaluation of clinical practice.

The critical examination of clinical practice should be an integral part of patient care. It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided. Clinical audit has not been successful in achieving this. The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice. Improvements are achieved by frequently revising the pathways to reflect current, local best practice. Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time-scale. A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment. A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence-based medicine. It is usually unique to the institution in which it was developed. The pathway forms part of the clinical record of every patient. All variations from the pathway are documented, and the reasons for the variations analysed. Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements. Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored. Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re-evaluated.

Clinical Medicine↗
PubMed1998

Multiple atrioventricular nodal pathways in humans: electrophysiologic demonstration and characterization.

INTRODUCTION: Multiple AV nodal pathway physiology can be demonstrated in certain patients with clinical AV reentrant tachycardia. METHODS AND RESULTS: Evidence suggesting multiple AV nodal pathway conduction was present in seven (two males; age range 15 to 75 years) of 78 patients (9%) who underwent electrophysiologic studies for AV nodal tachycardia. The presence of two discrete discontinuities in the AV nodal conduction curves suggested triple AV nodal pathway conduction. Detailed mapping of their retrograde atrial activation sequence was performed along the tricuspid annulus from the coronary sinus ostium to the His-bundle electrogram recording site. Three zones (anterior, middle, and posterior) correspond to the upper, middle, and lower third of the triangle of Koch, respectively. The fast pathway exits were determined as anterior (4/7) or middle (3/7), the intermediate pathway exits as middle (4/7) or posterior (3/7), and the slow pathway exits as middle (1/7) or posterior (6/7). Other evidence suggesting multiple AV nodal pathway conduction includes: (1) triple ventricular depolarizations from a single atrial impulse; (2) sequential dual ventricular echoes; (3) spontaneous transformation between the slow-fast and fast-slow forms of AV nodal reentrant tachycardia; and (4) persistent cycle length alternans during AV nodal reentrant tachycardia. In four patients, all three pathways were shown to be involved in AV nodal echoes or reentrant tachycardia. CONCLUSION: Multiple AV nodal pathways are not uncommon and can be identified by careful electrophysiologic elucidation and mapping technique.

Adolescent↗
PubMed1999

Effects of a pneumonia clinical pathway on time to antibiotic treatment, length of stay, and mortality.

OBJECTIVES: A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors' patients as compared with those in a "benchmark" hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later. METHODS: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10-12 months after implementation of the pathway, and 3) 34-36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community-acquired, community-acquired penicillin-allergic, nursing home-acquired, and nursing home-acquired penicillin-allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record. RESULTS: The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in-hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. CONCLUSIONS: This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three-year study interval.

Aged↗
PubMed1994

Inputs to group II-activated midlumbar interneurones from descending motor pathways in the cat.

1. Connections from descending motor pathways to group II-activated interneurones in the midlumbar segments of the spinal cord have been examined by intracellular recording. Interneurones, many of which had axonal projections to the hindlimb motor nuclei, were tested for inputs from rubro-, reticulo-, vestibulo- or corticospinal fibres. 2. Of 138 cells, 113 were monosynaptically excited by electrical stimulation of at least one of the descending motor pathways. Monosynaptic excitation from reticulo-, vestibulo- and rubrospinal pathways was common. Monosynaptic corticospinal EPSPs were identified in fewer neurones. 3. Convergent monosynaptic inputs from pathways which descend in the ventrolateral and ventral funiculi were common. Although few neurones with monosynaptic input from the corticospinal tract were identified, most also had monosynaptic rubrospinal input. In contrast, few neurones (4.3%) had convergent monosynaptic input both from pathways in the dorsolateral funiculus and from fibres in the ventral/ventrolateral funiculi. 4. The patterns of convergence from the different descending motor pathways differ from the patterns expected if the descending connections were distributed independently. Thus there is a significant segregation between rubrospinal and reticulo- or vestibulospinal inputs, and a significant association of reticulo- and vestibulospinal inputs. 5. Since descending motor pathways make monosynaptic connections with most group II-activated midlumbar neurones, many of which project to the hindlimb motor nuclei, some of these neurones provide a disynaptic pathway for the supraspinal control of hindlimb movements. The distribution of descending connections is consistent with the hypothesis that pathways descending in the dorsal part of the lateral funiculus and those descending in the ventrolateral or ventral funiculi contact different sets of interneurones.

Animals↗
PubMed1979

Activation of the alternative complement pathway by L-phase variants of gram-positive bacteria.

The present studies were performed to investigate the potential role of the alternative complement pathway in the host's defense against bacterial L-phase variants and to gain insight into the subcellular component of gram-positive bacteria responsible for activation of the alternative pathway. L-phase variants of Staphylococcus aureus and Streptococcus faecalis were able to activate the alternative pathway and consume C3 in C4-deficient guinea pig serum in amounts comparable to their respective bacterial-phase parent organisms. Activation of the complement system via the alternative pathway resulted in death of the L-phase variants. Membranes prepared from S. faecalis L-phase variants, by either osmotic lysis or mechanical disruption, retained their ability to activate the alternative pathway. Treatment of the membranes by three different methods (water washes, hot trichloroacetic acid, and cold trichloroacetic acid) resulted in a greatly diminished ability of the membranes to activate the alternative pathway. In addition, the extracts derived from the membranes by water washes and by cold-trichloroacetic acid treatment were able to activate the alternative pathway. These studies indicate that these L-phase variants can activate the alternative pathway and suggest that membrane-associated factors play a role in the alternative pathway activation by S. faecalis L-phase variants.

Animals↗
PubMed2004

Involvement of the lectin pathway of complement activation in antimicrobial immune defense during experimental septic peritonitis.

A critical first line of defense against infection is constituted by the binding of natural antibodies to microbial surfaces, activating the complement system via the classical complement activation pathway. In this function, the classical activation pathway is supported and amplified by two antibody-independent complement activation routes, i.e., the lectin pathway and the alternative pathway. We studied the contribution of the different complement activation pathways in the host defense against experimental polymicrobial peritonitis induced by cecal ligation and puncture by using mice deficient in either C1q or factors B and C2. The C1q-deficient mice lack the classical complement activation pathway. While infection-induced mortality of wild-type mice was 27%, mortality of C1q-deficient mice was increased to 60%. Mice with a deficiency of both factors B and C2 lack complement activation via the classical, the alternative, and the lectin pathways and exhibit a mortality of 92%, indicating a significant contribution of the lectin and alternative pathways of complement activation to survival. For 14 days after infection, mannan-binding lectin (MBL)-dependent activation of C4 was compromised. Serum MBL-A and MBL-C levels were significantly reduced for 1 week, possibly due to consumption. mRNA expression profiles did not lend support for either of the two MBL genes to respond as typical acute-phase genes. Our results demonstrate a long-lasting depletion of MBL-A and MBL-C from serum during microbial infection and underline the importance of both the lectin and the alternative pathways for antimicrobial immune defense.

Animals↗
PubMed1987

Differential electrophysiologic properties of decremental retrograde pathways in long RP' tachycardia.

Long RP' supraventricular tachycardias (SVT) often demonstrate both slow and decremental conduction properties in the retrograde pathway of the reentrant circuit. The electrophysiologic properties of these pathways are poorly understood. We studied 10 patients with long RP' SVT (RP'/RR, 0.52 to 0.71); five had the unusual form of atrioventricular nodal reentry (fast-slow) and five patients had accessory AV pathways with slow, decremental retrograde conduction properties. During SVT, the effects of intravenous adenosine (37.5 to 150 micrograms/kg), which increases potassium current (iK) in supraventricular tissue and hyperpolarizes membrane potential toward Ek (-90 mV), and the response to slow-inward channel blockade with verapamil (0.10 to 0.20 mg/kg iv) were evaluated. Adenosine and verapamil has similar effects in the presence of fast-slow AV nodal reentry since both agents terminated SVT by producing block in the retrograde slow AV nodal pathway. In contrast, adenosine and verapamil had differential effects on retrograde conduction in decremental accessory pathways. Adenosine terminated all episodes of SVT in the retrograde decremental pathway, whereas verapamil had a direct effect on this tissue in only two of five patients. Decremental retrograde accessory pathways can therefore demonstrate at least two types of electrophysiologic responses. Pathways that respond only to adenosine-induced hyperpolarizing K+ current likely comprise depressed fast-Na+ channel tissue, i.e., partially depolarized (greater than -60 to -70 mV) atrial tissue. In contrast, decremental accessory pathways that respond to both modulation of the slow-inward calcium current and K+ conductance have pharmacologic properties similar to those of the AV node and may represent more completely depolarized atrial fibers with resting membrane potentials of -60 mV or less.

Adenosine↗
PubMed1992

Preservation of atrioventricular nodal conduction during radiofrequency current catheter ablation of midseptal accessory pathways.

BACKGROUND: Septal accessory atrioventricular (AV) pathways may be located in close vicinity of the His bundle-AV nodal conduction system. Attempts at surgical or electrical interruption of these pathways may therefore result in impairment of normal AV conduction. This study focuses on a subset of septal pathways with an atrial insertion located inside the triangle of Koch. In this study, they were called "midseptal." METHODS AND RESULTS: Six patients with a midseptal accessory pathway (mean +/- SD age, 40 +/- 12 years; five with Wolff-Parkinson-White syndrome and one with a concealed accessory pathway) underwent attempts at ablation of their pathway using 500-kHz radiofrequency current applied to the atrial insertion of the accessory connection. Guided by the recording of accessory pathway activation potentials, the ablation catheter was positioned in all patients in an area bounded anteriorly by the tip electrode of the His bundle catheter and posteriorly by the coronary sinus ostium. All pathways were successfully ablated without the induction of complete heart block. First-degree AV conduction block occurred in one patient in whom a concealed accessory connection was located closer to the AV node than to the coronary sinus ostium. CONCLUSIONS: Radiofrequency current catheter ablation may be used effectively for midseptal accessory pathways and should be preferred in experienced centers as a safe alternative to surgical therapy.

Adult↗
PubMed1979

Deficient alternative complement pathway activity in newborn sera.

Neonatal susceptibility to overwhelming bacterial infection is commonly attributed to a relative deficiency in serum opsonic activity. However, few studies have compared the functional capacity of the classical complement pathway with that of the alternative complement pathway in the neonate. The opsonic activity of nine maternal infant serum pairs were studied by determining percent uptake of radiolabeled Escherichia coli. Seven mother-infant paired sera were studied using E. coli strains known to be opsonized via the alternative complement pathway: the mean percent uptake of E. coli opsonized in neonatal sera was 16.8%; of those opsonized in maternal sera, 54%; and of those opsonized in control sera, 45% (P less than 0.005). Two E. coli strains requiring the classical complement pathway for opsonization were phagocytized equally well in maternal and infant sera of seven mother-infant pairs. Determination of anti-O hemagglutination inhibition (HI) antibody titers in six maternal sera for one classical complement pathway activating and one alternative complement pathway strain showed no correlation between percent phagocytosis and HI antibody titer. These data would suggest that serum levels of classical pathway components are probably adequate for opsonization of E. coli via the classical pathway, but that low alternative complement pathway activity in neonatal sera may contribute to the newborn's increased susceptibility to bacterial sepsis.

Complement Activation↗
PubMed2004

Dual antennular chemosensory pathways can mediate orientation by Caribbean spiny lobsters in naturalistic flow conditions.

Benthic crustaceans rely on chemical stimuli to mediate a diversity of behaviors ranging from food localization and predator avoidance to den selection, conspecific interactions and grooming. To accomplish these tasks, Caribbean spiny lobsters (Panulirus argus) rely on a complex chemosensory system that is organized into two parallel chemosensory pathways originating in diverse populations of antennular sensilla and projecting to distinct neuropils within the brain. Chemosensory neurons associated with aesthetasc sensilla project to the glomerular olfactory lobes (the aesthetasc pathway), whereas those associated with non-aesthetasc sensilla project to the stratified lateral antennular neuropils and the unstructured median antennular neuropil (the non-aesthetasc pathway). Although the pathways differ anatomically, unique roles for each in odor-mediated behaviors have not been established. This study investigates the importance of each pathway for orientation by determining whether aesthetasc or non-aesthetasc sensilla are necessary and sufficient for a lobster to locate the source of a 2 m-distant food odor stimulus in a 5000-liter seawater flume under controlled flow conditions. To assess the importance of each pathway for this task, we selectively ablated specific populations of sensilla on the antennular flagella and compared the searching behavior of ablated animals to that of intact controls. Our results show that either the aesthetasc or the non-aesthetasc pathway alone is sufficient to mediate the behavior and that neither pathway alone is necessary. Under the current experimental conditions, there appears to be a high degree of functional overlap between the pathways for food localization behavior.

Afferent Pathways↗
PubMed2005

Peripheral pathways regulate motoneuron collateral dynamics.

Motor axons regenerating after repair of mixed nerve reinnervate pathways leading to muscle more often than those leading to skin [preferential motor reinnervation (PMR)]. Motoneurons that initially project collaterals to both muscle and skin prune incorrect projections to generate specificity. The number of motor axon collaterals maintained entirely within cutaneous or muscle pathways, however, is unknown. To overcome this shortcoming, dorsal root ganglion excision has been used to allow only motor axons to regenerate after a peripheral lesion. Motor axon number in reinnervated cutaneous and muscle pathways can then be correlated with the number of parent motoneurons determined by retrograde labeling. The number of collaterals per neuron can be calculated for each environment and the relative roles of pathway and end organ assessed by blocking the distal pathways to prevent target reinnervation. Without sensory competition, PMR develops in two stages: a limited response to muscle nerve and then a robust response to muscle that may involve retrograde signaling to the proximal pathway. Motoneurons maintain more collaterals in cutaneous nerve than in muscle nerve, even without muscle contact. This difference could result either from increased collateral formation in cutaneous nerve or from increased collateral pruning in muscle nerve. In either instance, these findings confirm that muscle and cutaneous pathways have functionally significant identities that can be recognized by motor axons and can regulate their arborization. Decreased arborization in muscle pathways could promote regeneration by focusing neuronal resources on high-yield projections; increased arborization in cutaneous pathways, conversely, would enhance pathfinding abilities.

Animals↗
PubMed2004

Role of a critical pathway for door-to-CT-completion interval in the management of acute ischemic stroke patients in the emergency room.

OBJECTIVE: Door-to-CT-completion interval (DCI) for acute ischemic stroke patients is one of the clinical indicators of quality assurance in an emergency room (ER). The aim was to clarify whether the critical pathway improves the DCI for acute stroke patients in the ER. METHODS: The pathway describes each step in patient evaluation in sequence from the patient's arrival in the ER until the brain CT is completed. Whether to use the pathway when evaluating individual patients is left to the discretion of the physician. After excluding 8 cases with insufficient data, 52 cases diagnosed with acute stroke (29 males, 69.9 +/- 12.4 y/o) in the ER between January and February 2003 were retrospectively identified. A logistic regression analysis was used to assess the impact of application of the pathway on achievement of an acceptable DCI (<25 min). RESULTS: The pathway was applied in 21.2% of the cases included in the study, and the median DCI was reduced from 48 minutes to 22 minutes as a result (P=0.02). Comparing them with the DCI, the probability values for ambulance use, consciousness disturbance, history of stroke, and application of the pathway in univariate analyses were less than 0.10. These variables were entered into the logistic analysis, which that indicated application of the pathway was the strongest variable related to acceptable DCI (OR: 10.92, 95% CI: 1.22 to 97.96). CONCLUSION: Application of the pathway was associated with an improvement of the DCI. Use of the pathway will improve the quality of the process of care in the ER.

Acute Disease↗
PubMed1981

Contrasting effects of clonidine and 5-hydroxytryptophan on spinal sympathetic pathways.

The effects of clonidine HCI were compared with those of 5-HTP on transmission through two spinal sympathetic pathways, segmental spinal reflex pathways and descending intraspinal excitatory pathways, in unanesthetized spinal cats. Evoked sympathetic discharges were recorded from upper thoracic preganglionic rami. Clonidine (5-50 microgram/kg) produced a parallel, dose-dependent depression of transmission through each pathway. The intraspinal pathway was five time more sensitive than the spinal reflex pathway (ED50's, 6 and 30 microgram/kg), and the spinal reflex pathway could not be depressed by more than 60% even by higher doses. In contrast, 5-HTP was more effective in depressing the spinal reflex than the intraspinal pathway (ED50's 32 and 44 mg/kg), and both pathways could be depressed completely. Small doses of tolazoline or yohimbine rapidly antagonized the effects of clonidine but not 5-HTP. Clonidine and 5-HTP appear to depress the excitability of sympathetic preganglionic neurons by activating alpha2- and 5-HT receptors, respectively. Each mechanism may contribute independently to regulation of the sympathetic outflow.

5-Hydroxytryptophan↗
PubMed1995

Critical pathways as a strategy for improving care: problems and potential.

In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.

Analysis of Variance↗