Analysis And Management Of Variations With Clinical Pathway Of Gastric Carcinoma In A Three Level Of First-class Hospital In Fujian Province

Objective This study aims to investigate the causes of variation problems with clinical pathway of gastric cancer in the clinical practice, and to propose reasonable measures based on the management of controllable variation factors.Methods To retrospectively analyze the variation factors with clinical pathway of 197 patients with gastric cancer in our hospital, and divide the patients into two groups: the group of patients followed the clinical path, and the group of patients exited the clinical path. We also divided the variation indicators into four aspects: variation from the development of disease, the requirements of patients, the medical staff and the hospital management system. In addition, variables were further classified into controllable and uncontrollable variations. Multivariable logistic regression analysis was applied to identify the possible reason why the clinical path was not followed. In addition, we analyzed whether the implement of clinical path have effects on the average in-hospital days and expenses in patients with gastric cancer.Results In the group of patients followed the clinical pathway, the variation ratio of disease factor, patient factor, medical staff factor and hospital management factor is 32.93%, 2.24%, 54.31% and 10.52%, respectively, in which controllable variation ratio is 64.83% and 35.17% for non-controllable variation. In the group of patients who exited the clinical path, the variation ratio of disease factor, patient factor, and medical staff factor is 61.29%, 22.58%, and 16.13%, respectively, in which controllable variation ratio is 83.87% and 16.13% for non-controllable variation. According to logistic regression analysis, the stage IV of gastric cancer(OR 72.74, 95%CI 8.80-601.17, P<0.001), incompliance of patients(OR 12.37, 95%CI 4.99-30.63, P<0.001), and severe postoperative complications(OR 4.29, 95%CI 1.38-13.32, P<0.05) are independent predictors for the presence of failure of completing the clinical path. Compared to the average in-hospital days(18 days) formulated in clinical pathway guideline by ministry of health, there were no significance difference of average in-hospital days(18.21±3.97 days) in patients followed the path(P>0.05). While average in-hospital expenses were higher than those formulated in clinical pathway guideline(P<0.05).Conclusion(1) Controllable variations are the main factors of variation with clinical pathway in patients with gastric cancer, therefore, the administrators in hospital should take effective measures against the controllable variability such as raising awareness of the medical staff of clinical pathways, strengthening the training of management and operations, and developing long-term and effective supervision and incentive measures. Moreover, leaders should coordinate cooperation among staff, and improve the construction of information platform of pathway in hospitals, in order to promote continuous improvement of the quality of clinical pathways.(2) The stage IV of gastric cancer, incompliance of patients, and long severe postoperative complications are main variation factors in patients who exited the clinical path, andwe can reduce serious variations that lead to making patients exit the path by strengthening the doctor-patient communication, taking elective hospitalizations and establishing "clinical pathway branch " mode.(3) Standardizing clinical process is an effective tool to shorten the average in-hospital days. Moreover, we need to reduce average in-hospital expenses by coordinating care and improving medical quality.