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PubMedDate not supplied

Effectiveness of a pneumonia clinical pathway: quality and financial outcomes.

In today's health care environment, it is imperative to evaluate planned changes within a health care system. We report the outcomes of a study on the effectiveness of a pneumonia clinical pathway. Important elements of effectiveness studies are discussed and used in presenting study findings. These findings are a preliminary demonstration that clinical pathways can improve patient and process outcomes. Their relation to financial outcomes is less clear.

Aged↗
PubMedDate not supplied

In search of pathways.

How can clinical pathways benefit patient care? With her NT/BHSF travel award, Karen Parsley travelled across the world to learn how Australian clinicians implement the system.

Australia↗
PubMed1999

Aberrations of the p53 pathway components p53, MDM2 and CDKN2A appear independent in diffuse large B cell lymphoma.

The two gene products of the CDKN2A gene, p16 and p19ARF, have recently been linked to each of two major tumour suppressor pathways in human carcinogenesis, the RB1 pathway and the p53 pathway. p16 inhibits the phosphorylation of the retinoblastoma gene product by cyclin D-dependent kinases, whereas p19ARF targets MDM2, a p53 inhibitory protein, for degradation. A deletion of CDKN2A would therefore disturb both pathways. To explore the p53 pathway genes as a functional unit in diffuse large B cell non-Hodgkin's lymphomas (DLCL), we wanted to see whether there exists mutually exclusiveness of aberrations of CDKN2A, MDM2 and p53, since this has not been analysed previously. We investigated 37 DLCL for aberrations of p15, p16, p19ARF, MDM2, and p53 at the epigenetic, genetic and/or protein levels. Homozygous deletion of CDKN2A was detected in seven (19%) of 37 tumours, and another three cases were hypermethylated at the 5' CpG island of p16. No point mutations were found in CDKN2B or CDKN2A. Immunohistochemical staining of formalin-fixed, paraffin-embedded tissue for p16 confirmed these results, as all tumours with alterations of CDKN2A were p16 immunonegative. We found p53 mutations in eight (22%) cases and MDM2 overexpression in 16 (43%) tumours. Twenty-three (62%) tumours had alterations of one or more p53 pathway components (p53, p19ARF and MDM2). Furthermore, 7/9 (78%) p16-immunonegative tumours showed co-aberration of p53 and/or MDM2. The lack of correlation between these aberrations suggests that DLCL acquire additional growth advantage by inactivating both of these critical regulatory pathways.

Cyclin-Dependent Kinase Inhibitor p16↗
PubMed2004

Regulation of signaling genes by TGFbeta during entry into dauer diapause in C. elegans.

BACKGROUND: When resources are scant, C. elegans larvae arrest as long-lived dauers under the control of insulin/IGF- and TGFbeta-related signaling pathways. However, critical questions remain regarding the regulation of this developmental event. How do three dozen insulin-like proteins regulate one tyrosine kinase receptor to control complex events in dauer, metabolism and aging? How are signals from the TGFbeta and insulin/IGF pathways integrated? What gene expression programs do these pathways regulate, and how do they control complex downstream events? RESULTS: We have identified genes that show different levels of expression in a comparison of wild-type L2 or L3 larvae (non-dauer) to TGFbeta mutants at similar developmental stages undergoing dauer formation. Many insulin/IGF pathway and other known dauer regulatory genes have changes in expression that suggest strong positive feedback by the TGFbeta pathway. In addition, many insulin-like ligand and novel genes with similarity to the extracellular domain of insulin/IGF receptors have altered expression. We have identified a large group of regulated genes with putative binding sites for the FOXO transcription factor, DAF-16. Genes with DAF-16 sites upstream of the transcription start site tend to be upregulated, whereas genes with DAF-16 sites downstream of the coding region tend to be downregulated. Finally, we also see strong regulation of many novel hedgehog- and patched-related genes, hormone biosynthetic genes, cell cycle genes, and other regulatory genes. CONCLUSIONS: The feedback regulation of insulin/IGF pathway and other dauer genes that we observe would be predicted to amplify signals from the TGFbeta pathway; this amplification may serve to ensure a decisive choice between "dauer" and "non-dauer", even if environmental cues are ambiguous. Up and down regulation of insulin-like ligands and novel genes with similarity to the extracellular domain of insulin/IGF receptors suggests opposing roles for several members of these large gene families. Unlike in adults, most genes with putative DAF-16 binding sites are upregulated during dauer entry, suggesting that DAF-16 has different activity in dauer versus adult metabolism and aging. However, our observation that the position of putative DAF-16 binding sites is correlated with the direction of regulation suggests a novel method of achieving gene-specific regulation from a single pathway. We see evidence of TGFbeta-mediated regulation of several other classes of regulatory genes, and we discuss possible functions of these genes in dauer formation.

Aging↗
PubMed2006

A new approach to systematization of the management of paper-based clinical pathways.

The present study was performed to explore a new approach to systematization of the management of paper-based clinical pathways by developing a new system requiring little capital investment. A new system was developed and incorporated into an existing network at a hospital with a paper-based clinical pathway management system. The effectiveness of this new system was examined by comparing the management efficiency of clinical pathways before and after its introduction, and by comparison of the new system with other such systems currently in place at other medical institutions with regard to efficiency. In addition, the acceptability of the system for other medical institutions was examined by providing free access to the software on the Internet. The development costs of the new system were low. Although the new system has been in place for more than 3 years, no problems have yet been encountered in either the existing network system or in the management system itself. The new system allows the processing of statistics and analysis of circulation or variance automatically, neither of which were possible in the original paper-based system. We provided open access to the system as free software on the Internet, and it has since been downloaded by many medical institutions and enterprises in Japan. This system is very useful for institutions where it is difficult to introduce expensive new systems for systematic management of clinical pathways, such as electronic medical records, because of problems regarding capital or system management, and it may also be useful in other countries.

Critical Pathways↗
PubMed1999

Implementation of a clinical pathway decreases length of stay and cost for bowel resection.

OBJECTIVE: To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay. SUMMARY BACKGROUND DATA: Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high. METHODS: A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway). RESULTS: The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups). CONCLUSIONS: Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.

Costs and Cost Analysis↗
PubMed2000

Taking the path less traveled.

Behavioral health is a new area for clinical pathways. Learn the steps to develop one, the pitfalls and benefits, and how to support your continuous quality-improvement efforts.

Critical Pathways↗
PubMed2000

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

Adult↗
PubMed1997

A clinical view of pathways of care in disease management.

Pathways of care define in detail the individual components of treatment for a group of patients. A well written pathway can give rise to consistent care or the highest quality. There are both educational and audit advantages to the approach. Details the means by which groups are selected and the care pathways written. Gives an example of the benefits that can accrue, based on the authors' experience at Ashford Hospital, UK of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved and costs contained.

Analysis of Variance↗
PubMedDate not supplied

Introduction of integrated care pathways for patients with multiple sclerosis in an inpatient neurorehabilitation setting.

Rehabilitation of progressive neurological disorders such as multiple sclerosis poses particular problems, and clear setting of goals and clinical audit are essential for effective management. Integrated care pathways (ICPs) offer a unique opportunity to document and audit the rehabilitation process. This preliminary study has shown that ICPs are useful in both assessing process and auditing goals. Their introduction has led to the identification of the key worker role within the neurorehabilitation unit (NRU), and has provided an opportunity to increase the participation of patients and carers in the rehabilitation process. Continuing refinement of the pathway is necessary, and its application to other neurological disorders such as cerebrovascular accident may be appropriate.

Activities of Daily Living↗
PubMed1999

Defining optimal management in ALS: from first symptoms to announcement.

The advances in treatment for amyotrophic lateral sclerosis (ALS) have demonstrated the need to diagnose this disease precisely and directly. Two international initiatives, at El Escorial in 1990 and at Airlie House in 1998, have grappled with the clinical and laboratory elements that may accelerate the diagnostic process. Shortly after the Airlie House meeting in 1998, an international group of clinical neurologists met to discuss optimal management strategies in ALS. The goals were to examine current diagnosis and treatment pathways and to attempt to devise an algorithm that would foster early diagnosis, thus enhancing the possibility of optimal treatment.

Algorithms↗
PubMed2006

[Effects of implementing clinical pathways for the care of patients undergoing ophthalmic surgery for cataract, glaucoma, and vitreoretinal disorder].

PURPOSE: To evaluate the actual use of clinical pathways and variances, and compare the length of hospital stay for surgery of cataract, glaucoma, and vitreoretinal disorder. METHODS: We designed eight types of clinical pathways for the treatment of cataract, glaucoma, and retinal-vitreous disease. We performed 102 phacoemulsifications and intraocular lens (IOL) implantations, 19 glaucoma or combined trabeculotomy and phacoemulsification/IOL, and 69 retinal-vitreous surgeries during a 1-year period from February 2002. We compared the length of the hospital stay before and after clinical pathway implementation. RESULTS: We applied the clinical pathways to 102 eyes (100%) of 67 patients undergoing phacoemulsification/IOL, to 17 eyes (89.5%) of those undergoing glaucoma surgery, and to 69 eyes (100%) of those undergoing retinal-vitreous surgery. The vaiances occurred in 20 eyes (29.9%) of 67 phacoemulsification/IOLs, 6 eyes (31.6%) of glaucoma, and 24 eyes (34.2%) of retinal-vitreous surgery. The length of hospital stay was shortened in phacomulsification/IOL after clinical pathway implemenation: 7.8 +/- 3.3 to 6.7 +/- 2.5 (mean +/- standard deviation) days. Glaucoma patients had a significantly shorter stay, from 16.4 +/- 5.0 to 12.6 +/- 3.3 days Mann-Whitney U test ; p = 0.032), and the hospital tay for retinal-vitreous surgery was shortened rom 22.8 +/- 11.1 to 17.9 +/- 6.2 days (p = 0.001). CONCLUSIONS: The application of clinical pathways resulted in substantially reduced hospital stay.

Cataract Extraction↗
PubMed2000

Inhibition of NF-kappa B activation by arsenite through reaction with a critical cysteine in the activation loop of Ikappa B kinase.

Arsenite is a potent environmental toxin that causes various pathologies including cancers and skin disorders. Arsenite is believed to exert its biological effects through reaction with exposed sulfhydryl groups, especially pairs of adjacent thiols. Here, we describe the mechanism by which arsenite affects the NF-kappaB signaling pathway. Activation of transcription factor NF-kappaB depends on the integrity of the IkappaB kinase (IKK) complex. We found that arsenite potently inhibits NF-kappaB and IKK activation by binding to Cys-179 in the activation loop of the IKK catalytic subunits, IKKalpha/beta. The affinity of IKKbeta for trivalent arsenic was verified in vitro by the ability of IKKbeta to enhance the fluorescence of an arsenic-substituted fluorescein dye. The addition of 1,2-dithiol antidotes or replacement of Cys-179 with an alanine residue abolished dye binding to and arsenite inhibition of IKKbeta. Overexpression of IKKbeta (C179A) protects NF-kappaB from inhibition by arsenite, indicating that despite the involvement of a large number of distinct gene products in this activation pathway, the critical target for inhibition by arsenite is on the IKK catalytic subunits.

Amino Acid Sequence↗
PubMed2002

Improvement of practice performance in urological surgery via clinical pathway implementation.

The purpose of this study was to compare performance measurements to evaluate the effects of clinical pathway implementation on improving practice performances in urology. Since April 1997, a total of 18 clinical pathways have been created in the urology department. Of these clinical pathways, six were implemented for endoscopic surgery, and four and eight were for minor and major surgery, respectively. Eight prominent performance measurements, which were identified as representative indicators of the practice performances, were selected in endoscopic surgery, five in minor surgery, and 11 in major surgery. Between April 1997 and March 1999, 2,883 consecutive patients, who underwent endoscopic surgery, minor surgery, and major surgery, were evaluated herein. The treatment results for patients in the first and second years of clinical pathway implementation were compared to those from the year preceding the implementation. In endoscopic surgery, five of the eight performance measurements improved significantly in the first year of implementation. Notably, three of the five improved performances continued to improve in the second year. Similarly, in minor surgery, four of the five performance measurements improved significantly following 2 years. Finally, in major urological surgery, six of the 11 performance measurements also improved significantly after 1 year; four of which continued to improve during the second year. Therefore, we conclude that patient care, which is based on the implementation of clinical pathways, can improve practice performances and facilitate medical care.

Critical Pathways↗
PubMed2004

Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia.

PURPOSE: To examine the impact of a unique evidence-based clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia (CAP). METHODS: A retrospective cohort study of CAP patients discharged between January 1999 and December 2001, from 31 Adventist Health System institutions nationwide. A total of 22,196 records were available for multivariate analyses. Odds ratios (OR) for the outcomes were calculated and stratified by a unique severity score. The severity score ranged from 1 to 5, where 5 indicated the most severe condition. RESULTS: Pathway patients were significantly less likely to die in-hospital compared with non-pathway patients in four of the five severity strata (OR in severity level 1=0.37; 95% confidence interval [CI], 0.20-0.70). In all severity strata, pathway patients were approximately twice as likely as non-pathway patients to receive blood cultures and appropriate antibiotic therapy. Among patients who were classified as severity level 1, pathway patients experienced an 80% reduction in the odds of respiratory failure requiring mechanical ventilation (OR=0.20; 95% CI, 0.12-0.33). CONCLUSIONS: Patients who were placed on pneumonia clinical pathway care were much more likely than non-pathway patients to have favorable outcomes of care.

Adolescent↗
PubMed2005

Critical role of the Rho-kinase pathway in TGF-beta2-dependent collagen gel contraction by retinal pigment epithelial cells.

Retinal pigment epithelial cells (RPEs) are thought to be one of the main components of fibrous membrane observed in eyes with proliferative vitreo-retinopathy. We investigated the signalling mechanisms of TGF-beta2-dependent collagen gel contraction by RPEs. An in vitro type I collagen gel contraction assay was performed to evaluate the effect of TGF-beta2 on gel contraction. The expression of alpha-smooth muscle actin (alpha-SMA) and the phosphorylation state of myosin light chain (MLC) were analyzed by Western blotting. The involvement of protein kinases such as p44/42 mitogen-activated protein kinase (MAPK), protein kinase C (PKC), p38 MAPK and phosphatidylinositol-3 kinase was investigated. The contribution of Rho-kinase and/or MLC-kinase was also evaluated using respective kinase inhibitors (Y27632, hydroxyfasudil and ML7). Additionally, RPEs were immunostained to examine whether the expression of alpha-SMA detected in our western blotting correlated to the stress fiber formation within the cells. TGF-beta2 caused time (0-5 days)-and dose (0 10 ng ml(-1))-dependent gel contraction associated with overexpression of alpha-SMA and phosphorylation of MLC (p < 0.01, respectively). PKC inhibitor (GF109203X, 5 microM) and p38 MAPK inhibitor (SB203580, 10 microM) significantly attenuated TGF-beta2-elicited gel contraction via partial downregulation of both alpha-SMA expression and MLC phosphorylation (p < 0.01, respectively). The gel contraction was prominently inhibited in the presence of Y27632 (10 microM) or hydroxyfasudil (10 microM) with strong suppression of MLC phosphorylation but had no significant effect on alpha-SMA expression. Treatment with ML7, in contrast, resulted in a marginal inhibition of MLC phosphorylation and gel contraction. Finally, pretreatment of the cells with Y27632 or hydroxyfasudil prevented the formation of stress fiber within the cells. These results indicate that TGF-beta2-dependent myofibroblastic transdifferentiation and MLC phosphorylation by RPEs involve both PKC and p38 MAPK pathways at least in part. Myofibroblastic transdifferentiation of RPEs appears to be independent of the Rho-kinase pathway, and the presence of alpha-SMA does not necessarily reflect the contractile potential of a cell. While Rho-kinase inhibitors are incapable of preventing myofibroblastic transdifferentiation itself, this pathway could be one of the critical targets of cell-mediated contraction of the tissue containing fibrillar collagens by transdifferentiated RPEs.

Actins↗
PubMed2003

Sonic hedgehog in normal and neoplastic proliferation: insight gained from human tumors and animal models.

Cancer arises when a cell accumulates multiple genetic changes that allow it to elude the highly regulated balance between proliferation and apoptosis that an organism employs to suppress inappropriate growth. It has become evident that malignant transformation of a cell or group of cells often involves pathways that are active during normal development but are inappropriately regulated in neoplastic proliferation. Signaling via the Sonic hedgehog pathway is critical to vertebrate development and also appears to play an integral role in the initiation and propagation of some tumors of the muscle, skin and nervous system. Analyses of human tumors have revealed mutations in various components of the Sonic hedgehog signaling pathway that appear to result in the activation of this pathway, as inferred by the increased expression of the transcription factor, Gli1. Interestingly, a proportion of the human tumors and most of those arising in mouse models continue to express the normal Patched allele, suggesting the involvement of additional molecular events in the transformation of the haploinsufficient cells.

Animals↗