A Study Of The Application Effect And Management Modes Of Clinical Pathways

Background:Since2009, Chinese Ministry of Health has launched clinical pathways program (CP) to standardize medical treatment procedure, which will improve healthcare quality, and will protect the healthcare safety as well. In2010, the hospital in this study was selected as one of the first batch of pilot hospitals by the Ministry of Health. In2011, Shanghai Municipal Health Bureau (SMHB) carried out the "Clinical Pathway and System Evaluation Demonstration Project", cooperated with America. This project was developed to assist SMHB in supervising compliance with China guidelines for hospital clinical excellence, effectiveness, and efficient hospital management. The hospital was selected as one of the three target hospitals. During the nearly3years, the hospital has accumulated experiences, collated the relative data and materials of clinical pathways, explored methods of clinical pathways management, and searched for the problems of clinical pathways. Clinical pathways have been carried out in domestic, but the studies of CP effectiveness on hospitals were mostly limited to the departments and diseases. There are less published literatures about CP impact on the overall hospital and less about comparisons of CP management modes. The purpose of this study was to investigate the overall impact of the hospital, during the implementation of CP; and to compare the effect of different CP management modes.Objectives:1) The study attemped to evaluate the effectiveness of clinical pathway when compared with traditional medical care. The impact of CP was evaluated by assessing healthcare service, healthcare costs, and medical efficiency. The overall impact of clinical pathways on hospital was assessed comprehensively.2) In specific case studies, to analyze the efficiency and quality of the disease before and after the implementation of CP and to compare the effect of CP;3) To analyze of the CP modes:simple CP management mode and PDCA (Plan, Do, Check, Action) mode, to compare the effect of differences under different CP management modes. Methods:Access to the information of the hospital from January2010to June2012, including the hospital bills, medical records, and satisfaction questionnaires, combined with expert advice, individual interviews, site surveys, questionnaires, the data of healthcare the service, healthcare costs, and medical efficiency were collated to make a comparison before and after CP implementation; and to compare medical staffs’CP cognition between initial implementation and mid-term of CP.During the period of clinical pathway implementation,3groups of ST-segment elevation myocardial infarction patients were selected according to the different phases. Group1included110patients before clinical pathway implementation; group2included75patients in the period of implementation; group3included75patients of demonstration projects of the PDCA plan.The observed indicators were the patient’s information in general, including gender, age, and so on. Quality indicators included90minutes PCI, patient outcomes, readmission, and patient satisfaction. Efficiency indicators included the length of stay in hospital, total hospital costs, the cost structure.The vertical and horizontal studies were conducted to compare and analyze before and after clinical pathway implementation, and to assess the effects of clinical pathways. The vertical study meant comparison before and after clinical pathway implementation, and after PDCA plan of clinical pathway; the horizontal study was comparing the special disease with the overall hospital, with other hospitals in the city, and with the peers in USA.Data processing used the SPSS16software, STATA11software, Excel. Measurement data alone groups were compared using independent samples t test between groups compared using ANOVA single-factor analysis of variance; X2test was used to compare the count data between the two groups. Hospital days in the case-the generalized linear model GLM Poisson regression, the total cost-the number GLM model; to P<0.05for the difference was statistically significant.Results:1) Results of the hospital:During the2years of clinical pathway implementation, in the case of almost the same number of beds, employees, outpatients, discharged patients, inpatient surgeries, and bed utilization, overall income showed an upward trend year by year. Compared with indicators of2011, those have been surpassed half in the first half of2012. Hospital preoperative average length of stay decreased from2.69days to1.49days, a decline of44.61%. The average length of stay decreased from10.81days to7.02days, a decline of35.06%. The average total cost of hospitalization dropped from14,789.23yuan14392.10yuan, a decline of2.69%.Drugs dropped from5663.65yuan3287.04yuan, a decline of41.96%. The proportion of unreasonable using of Antimicrobial drugs reduced from25.66%to less than5%.2) Overall results:studies have shown that hospital efficiency and quality has improved after the implementation of the cp, taking into account other conditions changed little, this improvement may be related to the implementation of cp. The medical staff surveys before and after the implementation of cp, further confirmed this conclusion.3) Case study results:Compared with group1and group2, group3had the shortest days of hospitalization; Age had a positive impact on the number of days of hospitalization. The total cost of Group2was the lowest, followed by group3, group1was the highest. The total cost of the patients paid by Medical Insurance was lower, and the cost of the ones without insurance was higher. The cost of males was higher, and the cost of females was lower.Taking into account the structure of cost, group3had the lowest pharmacy fees, the highest therapy cost, and the most expensive medical supplies.As to the PCI within90minutes, after PDCA plan, the completion rate was93.3%, exceeding both the target value of79%and the reference value of81%in the United States, and the rate also surpassed the value of89%, or mean of three demonstration hospitals after PDCA.The optimization of the average length of stay was8.53days, a decrease of12.15%compared to un-optimized clinical pathway group. But still higher than the target of8days, higher than8.41days, the mean of the three demonstration hospitals after PDCA.Conclusion:Although there are limitations in clinical pathway, such as without supports of Medical Insurance policies, without strong awareness of medical staffs, and no coverage of all diseases, the clinical pathway shows the advantages in regulating medical services, protecting of medical safety, shortening the average length of stay, improving the efficiency of medical, controlling medical costs, and improving patient satisfaction.PDCA management mode helps to promote CP or make continuous improvement of the medical quality and the medical efficiency.CP implementation has still good feasibility in the local area. Developing realistic CP in line with the hospital, and the rational using of limited health resources, can improve the quality of medical healthcare, and can elevate the competitiveness of the hospital as well.