The Application Of Clinical Pathway In Breast Cancer

Objective To collect and analysis randomized controlled trials and appraisal tool of clinical pathways, so as to analysis the research status on clinical pathway. Take breast cancer for example, our research used meta analysis to evaluate the use of clinical pathways (CPs) for breast cancer surgery when compared with usual medical care. Based on this we evaluated the use of clinical pathways for postoperative adjuvant chemotherapy in breast cancer.Methods ①The Cochrane Library, PubMed, EMBASE, Web of science, The Chinese Biomedical Database, China Journal Fulltext Database, WANFANG Database, were searched from inception to May 2013 to identify clinical pathways appraisal tools and randomized controlled trials. Two reviewers independently assessed the studies and extracted detail information.②Four English databases and four Chinese databases and Clinical Trials Registry Platform were searched from inception to November 2012 to identify randomized controlled trials (RCTs) that reported the effect of CPs for breast cancer. Included studies were assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Cochrane handbook. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software (version 5.2).③We conducted a historical cohort study. According to the inclusion criteria and exclusion criteria, we screened the cases undergoing postoperative adjuvant chemotherapy in breast cancer in the First Hospital of Lanzhou University from Jan.2012 to Dec. 2013, and divided them into two groups by whether or not they used clinical pathway. Between the two groups, we compared respectively about hospital stay, hospitalization costs, expenses for medicine, material, examination and test. SPSS 19.0 software was used to analyze data.Results ①328 randomized controlled trials and 7 clinical pathways appraisal tools were included.300 (91.5%) were published in Chinese, of which 292 were published on Chinese Science Citation Database journals.28(8.5%) English abstracts were all published on Science Citation Index journals. From 1999 to 2012, the number of RCTs was increased from 1(0.3%) to 72(22%).They majority RCTs focused on diseases of the circulatory system (18.6%), followed by digestive system (13.7%), neoplasms (11.3%), genitourinary system(10.4%) and respiratory system(10.4%).Based on the items of included appraisal tool,<clinical pathway management guidelines> published by the National Health and Family Planning Commission of the People’s Republic of China and the work of Vannhaecht, we analyzed five aspects involved organized, develop, implement, evaluation and improve of clinical pathway to identified 17 main characters of clinical pathway.②Six randomized controlled trials (571 patients) were included. There were 284 patients in the CPs group and 287 patients in the usual medical care group. The results showed that compared with usual medical care, CPs could significantly shorten the length of hospital stay [MD=-4.03d,95% confidence interval (-4.49,-3.57)], decreased hospitalization costs [SMD=-3.15,95%CI, (-3.53,-2.76)], preoperative hospitalization [MD=-0.54d,95%CI, (-0.71,-0.37)]and postoperative complications [OR=0.24,95%CI, (0.09,0.65)]. There was no statistically differences in patients’ satisfaction [OR=2.39,95%CI, (0.62,7.07)].③A total of 405 patients were included, of whom 213 were in clinical pathway groups, and 192 were in non-clinical pathway. According to the different chemotherapy, we divided patients into three subgroups:TC, TEC, TAC. Significant differences between clinical pathway group and non clinical pathway group were detected in three subgroups for hospital stay, hospitalization costs, expenses for medicine, expenses for test and Daily hospitalization costs(P<0.05);As to expense for material, there are significant differences between clinical pathway group and non clinical pathway group were detected in TC group; As to expenses for examination, there are significant were detected in TC and TEC (P<0.05) but not TAC(P>0.05); There were no significant statistically differences between the two groups in Average daily inspection fee for three subgroups.Conclusion In recent years, the number of clinical pathway RCTs is on a growth trend, shows the government pay more attention on it. In addition, the disease which involved by clinical pathway have extended to complex diseases and chronic diseases. Now the quantity and quality of clinical pathway appraisal tool are not measure up our expectation, we still needs to establish the perfect clinical pathway appraisal tools which can standardize the clinical pathway to ensure the medical quality and then improve its effects. The current evidence showed that CPs could effectively improve the quality of the care provided to the breast cancer surgery patient. It may be able to shorten the length of hospital stay, decreased hospitalization costs and preoperative hospitalization. The use of clinical pathways for postoperative adjuvant chemotherapy in breast cancer showed that the clinical pathway may be able to shorten the length of hospital stay, decreased hospitalization costs and expense for medicine and test, but increase daily hospital costs. The application effect is different for different chemotherapy in terms of expense for examining and test. In general, clinical pathway works best for TC group. As the study used a historical cohort approach, and may lead to biased conclusions, prospective studies are still needed to explore these issues clearly.