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PubMed2003

Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection.

BACKGROUND: Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. METHODS: One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. RESULTS: Mean total length of stay (+/- standard deviation [SD]) was less in the postclinical pathway patients (3.7 +/- 1.5 days) compared to preclinical pathway patients (6.6 +/- 3.3 days) (P <.001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant (P <.001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 +/- 2.8 days and in the prepathway patients was 6.9 +/- 4.1 days (P <.001). The average cost per patient (+/- standard error of the mean), with readmission costs added, was 9310 +/- 5170 US dollars in the prepathway group and 7070 +/- 3670 US dollars in the postpathway group (P =.002). CONCLUSIONS: The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay.

Adult↗
PubMed1998

Interdisciplinary quality improvement from the perspective of a clinical pathway team.

Clinical pathway teams are one type of interdisciplinary team formed to improve the quality of care provided to select patient populations. As they aim to improve quality, these teams look at improving the efficiency and effectiveness of the care provided, as well as overall performance. Some clinical pathways and teams are successful, while others are not. This article describes the activities of a coronary artery bypass graft (CABG) clinical pathway team, difficulties encountered by the team, and strategies developed to overcome these difficulties.

Coronary Artery Bypass↗
PubMed1998

Clinical pathways for family-oriented developmental care in the intensive care nursery.

The physiologic and neurodevelopmental benefits of developmentally sensitive nursing care for high-risk infants have been well documented. The remaining challenge is to find ways to introduce developmental care principles into busy intensive care nurseries. The article discusses the development of three clinical pathways designed around five areas for developmental intervention: environmental organization, structuring of nursing care, feeding, family involvement, and family education. Each pathway incorporated developmental principles appropriate for a different level of care; the level III pathway was designed for acutely ill or very premature infants, the level II pathway for infants recovering from acute illness or older premature infants, and the level I pathway for full-term infants. Introduction of the developmental care pathways had an immediate positive impact in the tertiary level intensive care nursery at Allegheny General Hospital.

Child Development↗
PubMed1997

Designing a care pathway for a maternity support service program in a rural health department.

Today's heath care system in the United States faces many financial dilemmas related to the country's current economic status. Despite dwindling resources, the health care system must continue to provide high quality care to meet ever-increasing demands (Ferguson, 1993). Care pathways are an example of case management tools which provide care coordination. With an interdisciplinary approach, pathways increase communication and continuity of care between service disciplines, as well as improve efficient resource utilization. The purpose of this paper was to review: (1) the literature related to the benefits of using care pathways to enhance client care; (2) the benefits of public health nurse home visitation to pregnant and postpartum women; and (3) to describe the process to design a care pathway for the Maternity Support Service (MSS) program at a rural health department. This health department provides MSS to a county with a population of 65,000, with over 900 births per year. The county is 100 miles wide and 28 miles long. Thus, the MSS staff cover a large area, and needed a method to maximize efficient use of staff time. Care pathways have tremendous appeal because they accommodate interdisciplinary teams of care, focus on process, reduce unnecessary variation in care, and attend to quality and client outcomes.

Critical Pathways↗
PubMedDate not supplied

Introduction to clinical pathways.

A clinical pathway is a comprehensive method of planning, delivering, and monitoring patient care. As efforts continue to streamline the delivery of services at all levels of care and settings, it is essential that quality management and utilization management professionals respond in a proactive manner to facilitate quality outcomes while decreasing cost and increasing efficiency. The use of clinical pathways, as one part of a facility's or an organization's total quality management program, may be the answer to this challenge.

Case Management↗
PubMedDate not supplied

The evolution of a hospital-based decentralized case management model.

The authors present a case study of a highly integrated case management program and the redefinition of the clinical practice model that evolved across the continuum of care as the integration process was achieved. The central leadership role of the clinical care coordinator (an advanced staff nurse role) as the front-line link between the case manager and the staff nurses was seen as one key in the model's success. Success was further enhanced by: development of objective-based versus time-oriented pathways; involvement of home health earlier, especially in the more complex discharge plans; and a refocus of the patient education process. Future initiatives include refocusing the patient education component as part of a "Steps to Recovery" approach that includes appropriate aspects of the objective-based clinical pathways and expanding the number of case management models to include currently underrepresented patient populations.

Case Management↗
PubMed2003

[Clinical pathway for inpatients with gastric ulcer: evaluation of usefulness].

Based on the results of a retrospective review of clinical data on inpatients with gastric ulcer treated at our department, we devised on original clinical pathway and tested it in the clinical setting. From the results obtained, we created an improved clinical pathway and evaluated its usefulness. The duration of hospitalization was 16.2 +/- 6.9 (mean +/- SD) days in the non-path group, 14.1 +/- 3.0 days in the original path group, and 10.9 +/- 2.0 days in the improved path group. The hospital time was significantly shorter in the improved path group. For patients with bleeding gastric ulcer, the duration of hospitalization was 18.0 +/- 6.3 days in the non-path group, 15.1 +/- 2.3 days in the original path group, and 11.2 +/- 1.8 days in the improved path group. This period was also significantly shorter in the improved path group. With regard to the occurrence of rebleeding from the gastric ulcers, there were no significant differences between the non-path group and both clinical path groups. These results indicate that devising a clinical pathway is useful for shortening the duration of hospitalization for patients with gastric ulcer.

Critical Pathways↗
PubMed2007

[Diagnostic procedure combination in gastric cancer treatment].

Present status and problems in diagnostic procedure combination (DPC) for treatment of gastric cancer are reviewed in this article. DPC for gastric malignancies are subgrouped by the presence or absence of operation, operative procedures and adjuvant treatment such as intensive care, radiotherapy and chemotherapy. In a comparison between prospective payment and medical cost invested, most investments can be recovered by DPC in patients who underwent mucosal resection or gastrectomy without major complications. However, in patients with postoperative complications who required intensive treatment,considerable investments can not be recovered by DPC. In patients given chemotherapy, most of the investments in conventional chemotherapy can be recovered by current DPC. The clinical pathway appears to be a useful tool to control homogeneously well-qualified investments in DPC.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1996

Integrated pathways for managing rural health services.

Rural providers must redefine their role in the changing health care system to include a more integrated approach to health care delivery. The rural provider must develop integrated pathways to coordinate all medical, behavior, and social services to ensure that appropriate services are available, locally or through linkages with other providers, for the population. The integrated pathway must manage care across the continuum of services and coordinate decisions occurring at the point of service.

Community-Institutional Relations↗
PubMed1997

Pathways to nowhere.

Early in the decade, health care discovered a powerful patient care management tool: the clinical path. Leaders in the field latched onto paths as the solution to cost and quality dilemmas, but they overlooked the importance of the underlying principles of quality management. Beyond Clinical Paths, a new book from American Hospital Publishing, focuses on the issues critical to successful quality improvement through clinical paths. The following excerpt by the book's editor, Patrice L. Spath, sets the stage for a new approach to clinical quality.

Critical Pathways↗
PubMed1998

A career path in clinical pathways.

Much like the development of a clinical path, the creation of a career path requires knowledge of patterns of behavior, needs for standardized education and skill development, along with variance analysis and individualized care. This nationally known nursing entrepreneur tells the story of her involvement in the development of case management and clinical pathways and how she turned that into a successful business that has changed how patient care is managed nationally and internationally.

Career Choice↗
PubMed1998

Quality and accreditation in nephrology. The Italian perspective. Management and quality control.

The economic approach of the industrial and commercial sector cannot be transferred to the medical one without proper measures. The final objective of the health service is not to gain profits but rather to achieve results in terms of health. Professional quality and, therefore, appropriateness becomes the foundation for proper management. In turn, appropriateness means to do the right things when they are useful regarding both the organisational, administrative, educational and training aspects and the medical ones. Management control is the right answer to this challenge to know and monitor consumption, strategies and results in relation to preestablished administration health policy objectives. Its purpose is to allow the organisation to carry out its objectives with the highest effectiveness and efficiency possible and it is joined with technical-professional elements which orient and support management in a logic of total quality. The adoption of the process of management control does not mean to turn doctors into managers. It must be hoped that doctors will understand the economic implications of the decisions made at clinical level as well as the technical-organisational ones. A medical action becomes effective if it is part of a system in which each person involved carries out his duties in an integrated logic where relationships are clearly defined. To decide what is appropriate, one refers to what is known and proven. It is clear that the problem of quality must be faced firmly and systematically. The activation of a quality program is not only based on the definition of "good practice", in terms of procedures, protocols, pathways and reference parameters for measuring quality but rather on the introduction of clinical methods that can guarantee a series of highly important opportunities.

Critical Pathways↗
PubMed2005

Cholangiocarcinoma: molecular targeting strategies for chemoprevention and therapy.

Cholangiocarcinomas are devastating cancers that are increasing in both their worldwide incidence and mortality rates. The challenges posed by these often lethal biliary tract cancers are daunting, with conventional treatment options being limited and the only hope for long-term survival being that of complete surgical resection of the tumor. Unfortunately, the vast majority of patients with cholangiocarcinoma typically seek treatment with advanced disease, and often these patients are deemed poor candidates for curative surgery. Moreover, conventional chemotherapy and radiation therapy have not been shown to be effective in prolonging long-term survival, and although photodynamic therapy combined with stenting has been reported to be effective as a palliative treatment, it is not curative. Thus, there is a real need to develop novel chemopreventive and adjuvant therapeutic strategies for cholangiocarcinoma based on exploiting select molecular targets that would impact in a significant way on clinical outcome. This review focuses on potential preventive targets in cholangiocarcinogenesis, such as inducible nitric oxide synthase, cyclooxygenase-2, and altered bile acid signaling pathways. In addition, molecular alterations related to dysregulation of cholangiocarcinoma cell growth and survival, aberrant gene expression, invasion and metastasis, and tumor microenvironment are described in the context of various clinical and pathological presentations. Moreover, an emphasis is placed on the importance of critical signaling pathways and postulated interactions, including those of ErbB-2, hepatocyte growth factor/Met, interleukin-6/glycoprotein130, cyclooxygenase-2, vascular endothelial growth factor, transforming growth factor-beta, MUC1 and MUC4, beta-catenin, telomerase, and Fas pathways as potential molecular therapeutic targets in cholangiocarcinoma.

Animals↗
PubMed2002

Overexpression of choline kinase is a frequent feature in human tumor-derived cell lines and in lung, prostate, and colorectal human cancers.

Carcinogenesis is a long process that results in the accumulation of genetic alterations primarily in genes involved in the regulation of signalling pathways relevant for the regulation of cell growth and the cell cycle. Alteration of additional genes regulating cell adhesion and migration, angiogenesis, apoptosis, and drug resistance confers to the cancer cells a more malignant phenotype. Genes that participate in the regulation of some critical metabolic pathways are also altered during this process. Choline kinase (ChoK) has been reported to belong to the latter family of cancer-related genes. Recently, we have reported that increased activity of ChoK is observed in human breast carcinomas. Here, we provide further evidence that ChoK dysregulation is a frequent event found in a variety of human tumors such as lung, colorectal, and prostate tumors. Furthermore, a large panel of human tumor-derived cell lines also show increased ChoK activity when compared to appropriate non-tumorigenic or primary cells. These findings strongly support the role of ChoK alterations in the carcinogenic process in human tumors, suggesting that ChoK could be used as a tumor marker.

Adult↗
PubMed2003

Identification of an endogenous ligand that activates pregnane X receptor-mediated sterol clearance.

The nuclear receptor PXR (pregnane X receptor) is a broad-specificity sensor that recognizes a wide variety of synthetic drugs and xenobiotic agents. On activation by these compounds, PXR coordinately induces a network of transporters, cytochrome P450 enzymes, and other genes that effectively clear xenobiotics from the liver and intestine. Like PXR, the majority of its target genes also possess a broad specificity for exogenous compounds. Thus, PXR is both a sensor and effector in a well integrated and generalized pathway for chemical immunity. Although it is clear that PXR responds to numerous foreign compounds, it is unclear whether it possesses an endogenous ligand. To address this issue, we noted that there is substantial overlap in the substrate specificities of PXR and its critical CYP3A target gene. This prompted us to ask whether endogenous CYP3A substrates also serve as PXR ligands. We demonstrate that 5beta-cholestane-3alpha,7alpha,12alpha-triol (triol), a cholesterol-derived CYP3A substrate, is a potent PXR agonist that effectively induces cyp3a expression in mice. This defines a critical salvage pathway that can be autoinduced to minimize triol accumulation. In contrast, triol can accumulate to very high levels in humans, and unlike mice, these people develop the severe clinical manifestations of cerebrotendinous xanthomatosis. The reason for these dramatic species differences has remained unclear. We now demonstrate that triol fails to activate human PXR or induce the CYP3A-salvage pathway. This explains why humans are more susceptible to sterol accumulation and suggests that synthetic ligands for human PXR could be used to treat cerebrotendinous xanthomatosis and other disorders of cholesterol excess.

Anesthetics↗
PubMed2003

Development of clinical pathway in S-1 chemotherapy for gastric cancer.

We have developed a clinical pathway to enable the safe continuous administration of S-1 (TS-1) in ambulatory care for patients with advanced gastric cancer. The S-1 clinical pathway includes a pathway for clinicians, a pathway for patients, and such assist tools as a medication diary, an explanatory document containing instructions relating to patient compliance, a table of associations between adverse reactions and prodromes, and general principles for dose reduction and withdrawal. These pathways and assist tools will improve the patient's perception of adverse reactions, thereby contributing to early discovery and rapid action against adverse events. The S-1 clinical pathway has been used with ten patients. S-1 administration has been continued in seven patients. In four of the seven patients, continued administration on the occurrence of adverse reactions was made possible by the use of appropriate measures such as drug withdrawal or dose reduction. It was confirmed that the S-1 clinical pathway was a useful tool for cancer chemotherapy in ambulatory care.

Adult↗
PubMed1997

Combining case management, pathways, and report cards for secondary cardiac prevention.

BACKGROUND: Many disease treatment tools can be shifted into prevention. Many cardiac rehabilitation programs have focused on a 12-week exercise plan with minimal long-term follow-up. In 1995 Butterworth Hospital established a cardiac prevention and rehabilitation program focusing on long-term modification of cardiovascular risk factors. CLINICAL PATHWAY: The pathway was created as the outpatient extension of three inpatient cardiovascular pathways. Unlike inpatient pathways, the outpatient pathway was integrated into the medical record as a major care planning and documentation tool. ENROLLMENT: Since the entry of the first group of patients in January 1995, average quarterly enrollment has increased from less than 15% to 32% of eligible patients. THE REPORT CARD: Butterworth adopted Dartmouth Medical Center's (Hanover, NH) value compass and instrument panel approach under the rubric of report card. As an internal, clinical quality improvement tool, the report card is not used for public reporting, although prevention and rehabilitation report cards are provided to payers. Information on cost and utilization, patient satisfaction, functional health status, and clinical outcomes, as well as the current improvement activities, are covered. Report cards have been issued in June 1996, September 1996, and January 1997, each highlighting activities that drive program improvements. CONCLUSION: The combination of case management, pathways, an outcomes database, and report cards creates a marketable program for secondary prevention of cardiac disease.

Cardiac Rehabilitation↗