Free Health Essays - Is There Evidence To Support The General Implementation Of Integrated Care Pathways: A Literature Review
In a recent article on variations in clinical , Professor Maynard states that by implementing and using standardised care pathways for high volume cases and chronic diseases, variations in standards of care could be improved. (Shannon 2004) Over the past decade there has been a plethora of Department of Health White Papers (1989, 1990, 1992, 1993, 1996, 1998, 1999, 2002) all aimed at reforming the National Health Service with an emphasis on a high - quality service organised around the individual patients. Each one highlighted the need for establishing partnership working between organisations and services, developing an infrastructure that supports practice and theory, team working and the promotion of evidence based practice.
In 1999, Clinical Governance (DOH 1998) was introduced and became an integral part of the 1999 NHS Act.
Clinical Governance is a framework through which the NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. (A First Class Service 1998)
Further developments have included the publication of new clinical guidance and new institutions have been formed. These organisations include:-
- The National Institute of Clinical excellence (NICE)
- Publication of National Service Framework (NSFs)
- The Commission for Health Improvement (CHI)
- The National Clinical Assessment Authority
- The NHS Plan
- General Medical Council plans for revalidation of doctors
- Corporate Governance, controls assurance and standards.
(Lugon, Secker-Walker 2001)
In order to meet the challenge of an integrated approach to the delivery of care a tool known as an `Integrated Care Pathway or Critical Care Map` has been adopted. (Riley 1998, Campbell et al 1998, Martin 2000) Poole 1999 supports this and argues that Integrated Care Pathways underpin the Clinical Governance initiative as the document sets out standardised, best practice clinical management in healthcare organisations.
1.1 DEFINING INTEGRATED CARE PATHWAYS
There are two key reasons why the definition of the term 'Integrated Care Pathways' has not been a straight forward task over recent years (National Programme for Information Technology 2004). The first of these relates to 'synonymy'. This refers to a situation in which two or more terms are used to describe the same fundamental concept. In the topic of focus for the current project, Care Pathways, Integrated Pathways and Clinical Care Pathways have all been used to refer to the same process. The second source of complexity in defining Integrated Care Pathways relates to the issue of 'homonymy'. This describes the case in which a single term is used to describe two or more concepts. With reference to Integrated Care Pathways, it is a term which has been used to refer to protocols, pathway and care plan. This ambiguity has facilitated some confusion within this area of research in that a standardised approach to what is meant by Integrated Care Pathways has not been clearly established.
In the past, care pathways have been developed and used locally by a ward, a department or an organisation. As long as clinicians using the care pathways have a clear understanding of the intended use of a care pathway, then there is no issue regarding what was being represented and what it was called. There was not a need for standardisation beyond their own boundaries. But with the introduction of the NCRS, electronic care pathway use and structure requires a certain degree of standardisation. To achieve standardisation the required concepts must be identified and their use and scope agreed. These concepts must then be named in ways that will work and be accepted nationally.
The following definition of Care Pathways was produced by the National Programme for Information Technology (2004). It was derived after discussions, reflections and refinements were made by the Care Pathways Expert Group for the Communications and Messaging Programme and the Clinical Design Group for the National Programme for Information Technology.
- A care pathway maps out a consistent set of decisions and activities relating to one or more issues or problems. The aim is to define a structured process of care in order to achieve specified goals. Care pathways present current best practices supported by an evidence base. A care pathway enables the variance between proposed and actual care to be audited, and best practice to be refined accordingly (National Programme for Information Technology 2004).
The current research will adopt this definition of Integrated Care Pathways for the purposes of the proposed literature review. A rationale for the current research project will now be provided.
1.2 RATIONALE FOR THE CURRENT RESEARCH
As the integration of the NHS and Social Care organisations and the integration of care delivery is now non-negotiable, the implementation and use of Integrated Care Pathways has taken on a more prominent role. This is further supported by the Commission for Health Improvement whose reports highlight the development of ICPs as recommended action where there is little or no evidence of integrated team working. There is an abundance of information on the use of Integrated Care Pathways but there is little evidence of objective measurements that supports the widespread adoption of their use.
A crucial stage involved with the implementation of any new conceptual process is evaluation. Clearly a new intervention will need to be developed, piloted and implemented effectively before it can be assessed in terms of both efficacy and effectiveness. It needs to be based upon a coherent rationale and to be a feasible option in addressing the issue for which it has been developed and designed. The efficacy needs to be demonstrated both economically and operationally whilst being perceived as a feasible approach by the staff whose role it is to implement the scheme. The effectiveness of the intervention needs also to be shown. Clearly if a new procedural approach does not improve the situation in the way in which it was designed to do, then the extent to which it is feasible will be somewhat irrelevant. The scope of the evaluation must also include a search for any negative aspects and consequences which are associated with the new intervention. This evaluation process needs to be fundamentally grounded in scientific principles and to take a systematic approach. The current research will consider the studies and investigations which have been conducted in order to evaluate the use of Integrated Care Pathways.
For the purpose of this research, a selection of literature published between 1998 and 2004 will be selected, reviewed and this will be interwoven with the authors thinking and experience to broaden the base of the research.
A personal interest in researching this topic developed as a result of taking up a new appointment as an employee of a training and consultancy company that specialised in supporting Integrated Care Pathway (ICP) evelopment, education and training. The author will now use the term ICPs throughout the rest of this enquiry.
Zander (1992) was the first person in the USA to develop the adoption of Care maps or Critical Pathways as a concept of total quality management when used at the point of delivery of care. Wall et al (1998) discusses how pathways provide a mechanism for integrating continuous quality improvement (CQI) efforts with traditional patient care reviews.
Recent Commission for Health Improvement reports have recommended the introduction and development of ICPs in areas where there is a lack of recognisable integration or multi-disciplinary work. (CHI Reports) The development and implementation of ICPs has been patchy throughout the UK. NHS Trust Boards and Trust Chief Executives have not received a mandate from the NHS Executive to implement ICPs or resources to support it so they have not featured on the top priority list. It could be argued that if ICPs were the vehicle to deliver changes in working practices, culture and standards of care, as both Zander (1992) Walsh (1998) and Wall et al (1997) suggest, resulting in NHS Trusts meeting their performance indicators a more proactive approach to their development by the NHS Executive could have been expected. This has further justified my interest in establishing the evidence to support the justification for developing and using ICPs when they take an enormous amount of time, effort and resources to implement.
The implementation of ICPs nationally appears to be inconsistent because there are variations in definition regarding the content and use of ICPs. There is a lot of anecdotal information available about how good they are (Johnson 1997, Zander 1992, Middleton et al 1998 and de Luc 2001), but there is very little objective evidence published that supports the view that Integrated Care Pathways in themselves result in changes to clinical practice or improvement in healthcare. (Campbell et all 1998, Overill 1998, Currie 1999). Some research has been conducted to investigate the current prevalence of the use of ICPs in the UK. For example, a recent evaluative NHS survey across the UK has been undertaken (Currie 1999). It was revealed that 86% of the respondents reported using ICPs to manage and organise care for particular client groups with physical conditions in the acute sector Although such research is useful in contributing to an overall picture of ICP usage, investigations which have evaluated such use also need to be considered so that a more comprehensive impression can be gained. Therefore an in-depth review of the literature is required in order to determine the ambiguity surrounding the use of this tool whilst also facilitating an evaluation of its efficacy and effectiveness. Therefore, this study is to systematically review the literature on the history and rationale for the justification of the use of Integrated Care Pathways.
1.3 RESEARCH AIM
The aim of the research is:-
A systematic review of selective literature for evidence to support and justify the development and implementation of Integrated Care Pathways.
2.0 METHODOLOGY OF IN-DEPTH LITERATURE REVIEW
A systematic review aims to integrate existing information from a comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias (Clarke & Oxman 2001, Khan, ter Reit, Glanville, Snowdon & Kleijnen 2001, Hart 1998, Mulrow 1994, Oxman & Guyatt 1993). In other words, a scientific approach will help to ensure that research evidence is either included or excluded based upon well defined and standardised criteria. This should ensure that the possible effects of researcher bias should be kept to a minimum. Brealey et al (1999) also states that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare.
2.1 REVIEWING PROCESS
Whenever one reviews or compares research reports, it is important that a clear set of criteria are established upon which the evaluations can be made. The reviewing tool to be used within this research will now be outlined and discussed to demonstrate how it was operationalised. The process has been adapted from that which was included within Brealey and Glenny (1999).
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Systematic Review (Summary of Framework) (Adapted from Brealey and Glenny 1999) |
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Identify the need |
Rationale, background information, existing work |
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Formulate problem and specify objectives |
Background, problem specification, objectives |
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Develop review protocol |
Design, resources, refinement |
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Literature search and study retrieval |
Sources, search strategy, documenting a search strategy |
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Assessing studies for inclusion |
Defined criteria, minimising reviewer bias, tables of studies included and excluded |
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Assessing and grading studies |
Appraising checklists, hierarchies of evidence |
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Extracting Data |
Data collection forms, extraction methodology |
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Synthesizing data |
Qualitative overview, quantitative synthesis |
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Interpreting results |
Strength of evidence implications of results |
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Disseminating and implementing results |
Methods of dissemination and implementation |
2.2 RESOURCES
As a part time student undertaking this review there will be financial and time restrictions. A personal computer will be used to access the Internet and the university library because of the distance between the researchers` home base and the university campus. The local hospital library facilities will also be accessed. Additionally other sources of information, such as the South East Area Pathways User Group (SEAPUG) and various Integrated Care Pathway websites will be accessed. A university Information Literacy Study Day on Databases and Journals will be attended to improve researching skills and techniques.
2.3 SOURCES OF DATA
The methodology employed within the research will involve obtaining data from four key sources: Computerised searches, Manual searches, the Internet and Other professionals working in the field. Each of these data sources will now be considered in more detail.
2.3.1 COMPUTERISED SEARCHES
The methods used in this research will include a detailed computerised literature search. Multiple databases, both online and CD-rom will be accessed to retrieve literature because they cite the majority of relevant texts. (Loy 200 Ford 1999) The computerised bibliographic databases are:-
MEDLINE
EMBASE
CINAHL
- OVIDON
British Nursing Index (BNI)
Cochrane
Science Direct (All Sciences Electronic Journals)
TRIP
However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve a comprehensive search (Sindhu & Dickson 1997, Ray & Vermeulen 1996 Farby 1993).
2.3.2 MANUAL SEARCHES
A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:-
- Books relevant to the topics from university libraries and web sites
- Inverse searching- by locating index terms of relevant journal articles and texts
- Systematically searching reference lists and bibliographies of relevant journal articles and texts
2.3.3 THE INTERNET
The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer.
Sites accessed will include:-
Department of Health
National Pathways Association
Specialist ICP conference organisers
Publishers of Medical Text
British Medical Journal
2.3.4 OTHER PROFESSIONALS IN THE AREA
Additionally, online discussion groups will be used as a method of contacting other investigators and specialists working in the field who may have unpublished work that has recently been completed (Sindhu & Dickson 1997).
This source of data has the potential to provide further anecdotal evidence and guidelines to resources which may not be highlighted within the other aspects of the methodology. As this is a relatively new research topic, it is likely that there is research which has been conducted but is yet to be published. Therefore, efforts will be taken to ensure that such data is included within the analysis.
In an area that has no clearly defined literature, the contribution of specialists is often essential (McManus et al.1998) other professionals will be contacted using:-
- Online discussion groups
- Local ICP support group
- Researchers and authors identified during literature review
2.4 IDENTIFICATION OF KEY WORDS
Databases use a controlled vocabulary of key words, in each citation. To assist direct retrieval of citations techniques Boolean logic will be applied using subject indexing, field searching and truncation to narrow the topic focus (Loy 2000, Hicks 1996, Goodman 1993). For this purpose Khan and colleagues (2001) propose that key words be based on the components of the review question.
An imaginative and resourceful technique of searching electronic databases will be used including recognising the inherent faults in the indexing of articles. Misclassification and misspelling will be included in the searches with searches utilising keywords and the subheadings, (Clarke, Greaves & James 1997, Greenhalgh 1997, Hicks 1996, Ray & Vermeulen 1996). A search strategy requires the ability to identify relevant articles and exclude irrelevant articles (Box 2) ( Khan et al 2001). Several permutations of terms will be used in order to identify the most relevant articles.
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Box 2. Comparison of literature Searching Terms (Adapted from NHS CRD Report No 4 -Khan et al.2001) |
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Sensitivity (recall) |
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Sensitivity is the proportion of relevant articles located by a search strategy, which is expressed as a percentage of all relevant articles on a specific topic. Thus the comprehensiveness of the ability to identify all relevant articles of the research strategy is determined |
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Specificity (precision) |
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Precision is the proportion of relevant articles located by a search strategy, which is expressed as a percentage of both relevant and irrelevant articles by the method. Hence the ability to exclude irrelevant articles is measured. |
Therefore, as suggested by Khan et al (2001), 'sensitivity' and ''specificity' are important issues when conducting searches of research on a database. The searches need to be as 'sensitive' as is possible to ensure that as many of the relevant articles are located. This may be a particularly salient issue with regards to the evaluation of ICPs as the number of appropriate entries may be limited. Thus an attempt to locate as many of these articles as possible becomes a more relevant and important objective. Furthermore, the search needs to be 'specific' In other words, it needs to be efficient where appropriate so that a higher number of the articles identified through a database search can be included and hence the time allocated to reviewing articles which are ultimately of no relevance, can be kept at an acceptable level.
2.5 INCLUSION AND EXCLUSION CRITERIA.
In order that a manageable quantity of pertinent literature is included in this study, it is essential that inclusion and exclusion criteria are applied. In order that a diverse perspective of the topic is examined broad criteria will be used. (KHAN et al 2001, Bannigan et al 1997) However, it is important to note that a balance needs to be achieved through which the scope of the inclusion criteria is sufficiently wide to include relevant articles whilst also being sufficiently specific such that the retrieval of an unmanageable set of articles is avoided.
2.5.1 Inclusion criteria:
The articles which are highlighted within the proposed searches will be assessed in terms of whether or not they meet the following criteria. Each article will need to be viewed as appropriate with regards to all of these constraints if they are to be included in the final analysis.
- A literature review encompassing all methodologies will be applied ( Petticrew 2003 McKee 1999)
- International Studies will be included
- Studies that have evaluated the use of ICPs in different services e.g. mental health, acute care, community care will be included.
- Studies that have evaluated the use of ICPs in specific areas of treatment will also be included.
2.5.2 Exclusion criteria
The articles highlighted by the searches will also be assessed in terms of whether or not they fulfil the following exclusion. If a potential relevant article meets one or more of these criteria then they will be immediately excluded from the data set and will not be included within the analysis stage of the methodology.
- It is not the purpose of this review to discuss the development of ICPs so studies focusing on this will be excluded
- Literature in foreign language will be excluded because of the cost and difficulties in obtaining translation.
- Research reported prior to 1998 will not be included within this review.
2.6 ESTABLISHING VALIDITY AND RELIABILITY
Clinical trials are extremely difficult to do well because of the huge number of possible biases and confounding variables, Publication bias can prejudice reviews because journal editors favour studies with findings that provide interesting reading, primarily in English (Alderson & Roberts 2000, Sutton, Duval, Tweedie, Abrams & Jones 2000 Goodman 1993). Where possible an attempt to access sources of evidence including unpublished work will be made to provide a balanced perspective and minimise prejudice (Hobbs et al 1998 Oxman 1994)
The accuracy of a review depends on the review question as well as on the quantity of evidence retrieved. (Khan et al 2001. Moher, Jahad, Nicol, Penman, Tugwell & Walsh 1995) Therefore it is essential that the exclusion criteria are kept to a minimum to ensure reliability.
2.7 CONSIDERATION OF ETHICAL ISSUES
Any research involving NHS patients/service users, carers, NHS data, organs or tissues, NHS staff, or premises requires the approval of a NHS research ethics committee (REC).(DH 2001) A literature review involves commenting on the work of others, work that is primarily published or in the public domain. This research methodology does not require access to confidential case records, staff, patients or clients so permission from an ethics committee is not required to carry out the review. However, it is essential to ensure that all direct quotes are correctly referenced. Permission must be sought form the correspondent before any personal communication may be used. All copyrights need to be acknowledged and referenced. The researcher will also act professionally when completing this report and ensure that research is identified, reviewed and reported accurately and on a scientific basis.
2.8 THE DATAANALYSIS STAGE
It is proposed that the evidence will be classified by the two areas of the study: justification and implementation.
Evidence will be collected and weighted by the level of evidence available on which the implementation of ICPS was decided and the rigor of the methodology used. A data extraction sheet will be designed to provide a tool via which the information within relevant articles can be summarised into a form which allow subsequent analysis.
2.9 ESTIMATED COSTS
The approximate costs which were incurred when completing the research are outlined below.
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FUNCTION |
AMOUNT REQUIRED |
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Administration, photocopying |
100 |
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Travel Expenses |
500 |
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Networking inc. Conference |
400 |
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Equipment Hire |
Nil |
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Equipment purchase |
Nil |
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Journal subscription purchase of books |
250 |
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Production and printing |
100 |
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Total amount required |
1350 |
Please note the approximate costs given o not include the cost of manpower but it is an indicator of project overheads. The researcher is not currently in fulltime employment and it is anticipated that personal financial commitments were covered by undertaking agency sessional employment as required.
Project Duration six months.
3.0 RESULTS
The results of theliterature search are displayed in the table below. The five most relevant articles which were included in the analysis are summarised. Information about each of the articles is provided regarding the Study title, Authors, the study's Objectives, the research Design, Population, Intervention, Methodology, the Outcome Measures which were used, Analysis, Results and other Comments. Five articles which were excluded from the analysis are detailed to provide examples of the kinds of study which was produced by the data source but not included within this research. For these excluded articles the Study title and authors are also given along with the reasons for the exclusion.
Table of included studies
(adapted from Brealey et al 1999)
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Study |
Integrated Care Pathways for Vascular Surgery: an analysis of the first 18 months. Post Graduate Medical Journal 2002; 78 :175-177 Sweeney AB Flora H S Chaloner E J Bucklend J Morrice C Barker S G E 2002 |
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Objectives |
A review of the use of previously described Integrated care Pathways (ICPs) established for three elective vascular surgical procedures. |
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Design |
A retrospective analysis of information gathered prospectively over an initial 18 months period of use of vascular surgical ICPs. |
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Population |
Patients admitted to a single vascular unit for open repair of abdominal aortic aneurysm (AAA) 12 patients, carotid endarterectomy 19 patients, or femoropopliteal bypass grafting 28 patients. Total of 59 patients |
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Intervention |
Recorded deviations from what was expected during the ICP standardised route of delivery of care recorded as a variance over an 18 month period between 1998 and 200 |
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Methods |
Uncontrolled before and after study. Purely retrospective. An analysis of variance data, length of stay, and costings after the use of ICPs. Compared with previous clinical practice. |
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Outcomes measured |
Variance data recorded on each of the three procedures who received ICP delivered care over a period of 18 months compared with a group of 28 patients admitted from the 12 month period immediately before the start of the study. |
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Analysis |
Overall there were 350 variance recordings: 28 femoropopliteal bypass patients had 162 variances recorded (mean 5.8) 12 AAA repairs had 104 (mean 8.7) 19 endarterectomies 84 variances (mean 4.4) The recording of variance was not good due in part to the few guidelines offered. This resulted in an accumulation of too much data of dubious relevance. 33% of categories of variances were classified as other 28% of variances covered medication 13% of variances covered delay in discharge 5.4% of variances covered gastrointestinal complications |
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Results |
A total of 59 patients were followed up in the study: 28 femoropopliteal bypass grafts, 19 carotid endarterectomies and 12 open repairs of AAA. The length of stay in comparison to the retrospective study patients were discharged:- 10% more quickly after open AAA repair 13% more quickly after carotid endarterectomies 37% more quickly after femoropopliteal bypass grafts, Cost savings of 25% or 65,604 per patient episode The ICP can be viewed as a framework to improve patient care. This study has enabled recommendations on how practice can be altered in an evidence based manner. The ICP has improved communications allowing greater nursing autonomy resulting in a reduction in calls to junior medical staff. |
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Comments |
An ICP pilot study had already been undertaken prior to this study. The original ICPs were developed on perceived best practice and anecdotal evidence on the use of ICPs. |
|
Study |
Randomised Control Trial of Integrated (Managed) Care Pathway for Stroke rehabilitation Stroke 2000; 31 1929-343 Sulch D Perez I Melbourn A Kalra L |
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Objectives |
To evaluate the effectiveness of ICP - based management in reducing the length of hospital stay without affecting functional outcome in stroke patients undergoing specialist rehabilitation. |
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Design |
Randomised control trial - but unclear whether study was blinded. Computer randomisation (in blocks of 10) |
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Population |
152 patients with stroke (all types)resulting in limitations of activities of daily living and required rehabilitation - CP group 76, control 76 Excluded patients with severe premorbid physical or cognitive disability. No patient dropped out or crossed over |
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Interventions |
Case managed care using an Integrated Care Pathway; multidisciplinary care with rehabilitation and discharge planning, pre=defined therapeutic activities, short - term goals and time projections. There were weekly multidisciplinary team meetings. |
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Method |
An ICP for stroke rehabilitation based on evidence of best practice, professional standards, and existing infrastructure was developed. Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were randomised to receive ICP care co-ordinated by an experienced nurse (n+76) or conventional multidisciplinary care (n=76) Control: Multidisciplinary care with weekly multidisciplinary teem meetings |
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Analysis |
Data on age, sex, stroke side, stroke subtype, neurological deficit and premorbid abilities were collected as baseline Barthel Activities of Daily Living index was assessed at b1, 4, 12 and 26 weeks. Hospital Anxiety and Depression scale assessed at 4, 12, and 26 weeks. Rankin Score and Euroqol Quality of Life Score assessed at 12 and 26 weeks Mortality, cause of death and discharge destination data collected up to 26 weeks Research assessments were undertaken by 2 observers who were not directly involved in patient care. In instances the Barthel XXXXX value 0.78 and Rankin xxxxxx value 0.86. If assessments differed, the observers reviewed the patient together to arrive at a consensus. |
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Results |
Length of Stay (days): CP=50+/-19 vs. Control=45 +/=23. Mortality at 6 months CP= 10/76 vs Control = 6/76 Discharged home: CP=56/76vs.54/76 Institutionalisation: CP=10/7 vs Control=16/76 Median Euroqol at 6 months: CP=63 vs Control =72. No difference in Barthel index, Rankin score, anxiety score, or depression score at 1, 3 or 6 months. No difference in duration of PT or OT input. Compliance to care pathway generally good Both groups similar characteristics. |
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Comment |
ICP management offered no benefit over conventional multidisciplinary care on stroke rehabilitation unit. Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care. |
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Study |
Does an Integrated Care Pathway improve processes of care in Stroke Rehabilitation? A randomised controlled trial Age and Ageing 2002;31: 175-179 Sulch D Evans A Melbourn A Kalra L |
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Objective |
To evaluate whether Integrated Care Pathways improve processes of care in stroke rehabilitation. |
|
Design |
Randomised control trial - but unclear whether study was blinded. Computer randomisation (in blocks of 10) |
|
Population |
The study included 152 patients with stroke (all types)resulting in limitations of activities of daily living and required rehabilitation transferred to a stroke rehabilitation unit within two weeks of an acute stroke (average age 75 +- 10 years; 51 men) who were allocated to management using the ICP (n=76) or conventional multidisciplinary care n=76). Their baseline demographic characteristics, stroke severity and disability levels were comparable. Patients with severe premorbid physical or cognitive disability were excluded |
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Intervention |
Patients were assigned to care led by the ICP and co-ordinated by a stroke nurse (n=76) or to conventional consultant - led MDT care (n=76). Interventions were provided in separate bed areas staffed by 2 teams who worked independently with little cross over of staff. |
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Methods |
Collection of data on processes of care using the Intercollegiate Stroke Audit Tool Additional information from completed formal neurological assessment and information provision on risk prevention. Case note reviews undertaken by two researchers blinded to patient allocation and not involved with patient care. Inter-rater reliability was assessed using kappa statistics by comparing evaluations undertaken independently by both observers in 20 patients randomly selected from both groups. |
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Outcomes Measured |
The main outcome measure was the proportion of patients receiving recommended interventions as defined in the Intercollegiate Stroke Audit Secondary outcome measures were compliance with the ICP and time taken to achieve the interventions against the predicted time frame. |
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Analysis |
ICP records in 76 patients showed good compliance in all domains assessed. Over 80% of prescribed interventions were completed by all disciplines. However the time taken to undertake these interventions varied considerably from the ICP in most of the domains assessed. Variations most marked were;- Occupational therapy 63% Physiotherapy 61% when interventions did not occur at the planned time. Over 50% of the processes involved in discharge planning were delayed as were one third of medical and nursing interventions. Most variances (68%) were due to patient factors, such as variability in recovery of intercurrent health problems. External factors were responsible for 23% and failures in interdisciplinary co-ordination for 9% of variances recorded. Incomplete documentation was seen in 22 (14%) records. |
|
Results |
Integrated Care Pathways methodology was associated with higher frequency of stroke specific assessments, notably testing for inattention (84% versus 60%; P=0.015) and nutritional assessments 74% versus 22% P< 0.024) and early discharge notification to general practitioners (80% versus 45%; P<0.001) were also common in this group. There were no significant differences in the processes of interdisciplinary co-ordination and patient management between integrated care pathways group and the control group. |
|
Comments |
Integrated care pathways may improve assessment and communication, even in specialist stroke settings. However their potential to improve outcomes of stroke in non-specialised wards is clear but remains unproven |
|
Study |
Integrated Care Pathways and Quality of Life on a Stroke Rehabilitation Unit. Stroke 2002; 33:1600 Sulch D Evans A Melbourn A Perez I Kalra L |
|
Design |
Retrospective comparative study. From 152 stroke patients randomised to receive integrated care pathway care or multidisciplinary care at six months after stroke. |
|
Population |
152 patients with stroke (all types) transferred to a stroke rehabilitation unit within 2 weeks of the acute event. Patients were excluded if they presented with mild deficits (specialist rehabilitation no indicated), very severe deficits (rehabilitation could not be commenced within 2 weeks), or severe premorbid physical or cognitive disability (limited scope for specialist stroke rehabilitation |
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Intervention |
Patients were assigned to care led by the ICP and co-ordinated by a stroke nurse (n=76) or to conventional consultant - led MDT care (n=76). Interventions were provided in separate bed areas staffed by 2 different teams of nurses but sharing medical and therapy input ( different therapist but within the same unit). The teams worked independently of each other with separate team meetings. In the ICP method therapeutic activities were grouped according to stage and predicted patient needs. Key goals for each therapeutic intervention and the time estimated to achieve Patients receiving conventional rehabilitation were assessed comprehensively for individual needs by the multidisciplinary team and a customised rehabilitation programme was designed under the supervision of a consultant. |
|
Methods |
A comparison of quality of life, caregiver strain and patient/caregiver satisfaction at 6 months after stroke was undertaken in 152 stroke patients randomised to receive ICP or MTD care. Differences in processes of care were recorded Multivariate analyses were undertaken to identify the effect of age, sex, stroke severity, functional status, mood, and use of care pathway on quality of life score. |
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Outcomes Measured |
Patient and caregiver satisfaction. Caregiver strain Quality of life outcomes with items such as functional recovery, quantity of therapy, information received and discharge planning. |
|
Analysis |
A sample size of 136 was calculated on the basis of length of stay, the primary end point in the original trial. Age and Orgogozo scores at baseline were compared with the t test for unpaired data. Proportions and heterogeneity of distributions for categorical values such as sex, premorbid functional abilities at baseline, processes of care, domains of EuroQol, and individual items of patient/caregiver satisfaction questionnaire were compared with the asymptotic test. Factors influencing overall QOL score were investigated by entering Euro=Qol scores into a univariate analysis against factors such as age, sex, stroke severity, use of care pathway, and functional status, as well as the individual EuroQol domains. The independent effect of the care pathway was investigated by undertaking multiple linear regression with stepwise deletion on the whole patient group (n=121), with the overall EuroQol score used as the dependant variable and factors found to be significant at the 20% level used as the explanatory variables. |
|
Results |
The 2 groups were comparable for baseline characteristics of age, sex, stroke severity and initial disability. MTD care was characterised by greater emphasis on return of higher function and caregiver needs compared with ICP. EuroQol Visual Analogue Scale (EQ-VAS) scores were higher in the MDT group (median, 72 versus 63; P<0.005), who also had higher scores for EuroQol dimensions of social functioning (P=0.014).Higher EQ-VAS scores were independently related to MTD care P=0.04), Rankin score (P=0.01), and psychological function (P<0.0001) but not to age, sex, or stroke severity. There were no significant differences in patient or care giver satisfaction between the 2 settings. |
|
Comments |
Led stroke rehabilitation on a specialist unit is associated with a poorer QOL than that achieved by conventional MTD management. Conventional care was better in striving to restore higher functional abilities and in supporting caregivers and was probably better in reducing caregiver strain, all of which may have contributed to improved social functioning in theses patients. |
|
Study |
The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study Age and Ageing 2004;33 178-184 Roberts H C, Pickering R M, Onslow E ,Clancy M, Powell J, Roberts A, Hughes K, Coulson D, Bray J |
|
Design |
A prospective study of patients admitted 12 months before and after implementation of a care pathway for the management of femoral neck fracture. Audit data for corresponding time periods from nearby orthopaedic units was used as comparators to control for secular trends. Length of stay data for the index hospitals acute elderly care wards was abstracted from its patient administration system. |
|
Population |
Patients aged 65 years and over with a diagnosis of new first time femoral neck fracture admitted to the index orthopaedic unit during the two 12 month study periods. |
|
Intervention |
The ICP covered patient care from admission through to discharge from there or the 12th post operative day (whichever was sooner) and was similar to ICPs developed for this condition in other hospitals, Clinical care given by medical, nursing, physiotherapy and occupational therapy staff was included, and variance was recorded. |
|
Methods |
Data collection on case mix (demographic details and pre-fracture function), process (operative details and reasons for delay) and outcomes from the clinical records and from the hospital patient administration system for all eligible patients in both time periods. |
|
Outcomes measured |
The primary outcome was length of stay. Secondary outcomes included ambulation at discharge, discharge destination in-hospital complications, 30 day mortality readmission within 30 days of discharge and the post operative days on which the patient first sat out of bed and walked. |
|
Analysis |
Length of stay was compared between the two groups in an analysis of covariance controlling for age; sex; confusion, ambulatory score and domicile at admission; and type of operation. The estimated difference was presented with associated 95% confidence intervals Unadjusted comparisons were also made using the Mann-Whitney U test. Continuous secondary outcomes were comparedin similar analysis of covariance, while binary secondary outcomes were compared in logistic regression models controlling for the same variables. Mean length of stay for each of the three elderly care wards in the index hospital were averaged. Audit data from the nearby orthopaedic units were compared using descriptive statistics. |
|
Results |
400 and 381 eligible patients were admitted during the two study periods, of which 395 (99%) and 369 (97%) clinical records were available for full analysis. The two study groups were similar with regard to pre-fracture demographics and function. More operative delays were experienced by the second group (64% versus 52%) for both medical and organisational reasons, and more of these operations were carried out by consultant staff. Bipolar hemi-arthroplasty was performed more often than Austin-Moor in the second group. The primary out come, length of stay on the index orthopaedic unit, showed a mean increase of 6.5 days (95% CI 3.5 - 9.5 days, P <0.0005) in the second group in controlled analysis. A statistical significant increase of 5.5 days persisted after excluding patients who died or were discharged to nursing/residential homes. Other outcomes of care were similar in both groups except for a significant increase in the ability to walk alone on discharge (P=0.033), and a non-significant reduction in admission to institutional care in the second group. Although the overall complication rate was similar in the two groups, the second group had significantly fewer wound infections (P=0.022) pressure sores (P=0.041) and urinary tract infections (P=0.038). However, this group also had more cardiac and carer-related events recorded the latter largely related to delays in home care support and in admission to residential/nursing homes. The second group received twice as much occupational therapy 304 contacts as opposed to 149 contacts. The assessment of transfers increased from 17-51, and the issue of equipment rose from 8-=25 contacts. There was an increase of involvement of :- occupational therapists in discharge planning ↑ 2-27 , discussions with the clinical team increased↑ 6-36 telephone calls increased ↑9-47 |
|
Comments |
The use of a care pathway for the delivery of care for older patients with hip fracture may have improved clinical outcomes but it was also associated with longer hospital stays and greater therapy use. The use of care pathways for the management of hip fracture patients can be a useful tool for raising care standards but may require additional resources. Theses findings are relevant to all those planning and providing care for this group of patients. |
CHARACTERISTICS OF EXCLUDED STUDIES
|
Study Peters J, Baxter T, Pollard S |
Evaluation of the development and implementation of a care pathway for myocardial infarction Journal of Integrated Care Pathways 2002 6 63-68 |
|
Reasons for exclusion |
This article described the process undertaken to aid care pathway development and not the evaluation of the impact on the delivery of care |
|
Study Ellershaw J, Smith C Overill S Walker SE Aldridge J |
Setting Standards for Symptom control in the Last 48 Hours of Life |
|
Reason for exclusion |
The aim of this study was to implement the ICP for care of the dying patients to develop measurable outcomes and set standards. |
|
Study Johnson KB Blaisdell CJ Walker A Eggleston P |
Effectiveness of a Clinical Pathway for Inpatient Asthma Management. Paediatrics Vol 106 No 5 November 2000, pp1006 -1012 |
|
Reason for exclusion |
The article described the effectiveness of a clinical pathway for Inpatient Asthma Management at a hospital in Baltimore Maryland and therefore did not meet the inclusion criteria. |
|
Study Bailey, R. Weinharten, S. Lewis, M. Mohsenifar, Z. |
Impact of Clinical Pathways and Practice Guidelines on the Management of Acute Exacerbations of Bronchial Asthma Chest, 1998, 1, 28-33 |
|
Reason for exclusion |
The article described the effectiveness of a clinical pathway for Inpatient Asthma Management at a hospital in Los Angeles and therefore did not meet the inclusion criteria. |
|
Study Calligaro, K. D. Dougherty, M. J. Raviola, C. A. Musser, D. J. De Laurentis, D. A. |
Impact of clinical pathways on hospital costs and early outcome after major vascular surgery 1995, 22 (6), 649-657 |
|
Reason for exclusion |
The purpose of this study was to determine whether there would be significant cost savings by introducing clinical pathways in a hospital in Philadelphia. |
4.0 DISCUSSION AND CONCLUSION
The following discussion will first consider the main findings of the systematic literature review. These will be analysed and related to the literature which was included within the introduction section of this report. The limitations of the methodology which was employed within this research will then be provided before a consideration is made of what future research in this field should focus upon.
4.1 RESEARCH FINDINGS
This research involved conducting a systematic review of the literature relating to Integrated Pathways. It particularly focussed upon the research evidence which evaluated the efficacy and effectiveness of the use of ICPs. The results section contained a summary of the five most relevant articles which were selected for inclusion within the analysis process. Details regarding five articles which were not included were provided along with the reason for their exclusion. Overall this body of research evidence highlights both possible advantages and disadvantages of the implementation of ICPs. These will now be considered in turn.
4.1.1 EVIDENCE FOR THE ADVANTAGES OF ICPs
Sweeney et al (2002) reviewed the use of ICP over an 18 month period. They focussed on the clinical progress of 59 patients who had undergone vascular surgery. It was reported that, for the different treatment groups there was a significant improvement in terms of the time at which the patient was discharged. This improvement ranged from 10-37%. Therefore, this would lead one to conclude that the implementation of ICPs can facilitate a reduction in the length of time that patients spend within the care setting. As discussed in the introduction, evaluations need to focus on the efficacy of an intervention as well as the level of effectiveness that it is associated with. Part of this efficacy assessment involves the cost of the new approach. Therefore it was interesting to note that Sweeney et al (2002) report that ICPs contributed to a 25% reduction in costs. This translated into an approximate saving of 65000 per patient. Clearly budgets and costings are always a key issue within the NHS and hence any process which can help to reduce costs is likely to be well received by those at a management level. The final important finding of the Sweeney et al (2002) study it that they observed a significant improvement in the level of autonomy experienced by the nurses. This was said to have been based upon an improved level of communication within the team. Therefore this study has demonstrated that ICPs have the potential to facilitate earlier discharges, reduce costs and to improve the nurses' sense of autonomy. Further benefits of the CIP approach have been highlighted within other related research.
A study was conducted to evaluate the effectiveness of ICPs within a Stroke rehabilitation unit. A sample of 152 patients were involved in the research. The researchers found that ICP was associated with an increase in the number of Stroke related patient assessments. For instance, the use of ICP saw a significant increase in the number of assessments regarding both attention and nutrition. An improvement was also observed regarding the early discharge notification which was sent to the patients' General Practitioners This lends some evidence to support the findings of the Sweeney et al (2002) study in that ICPs may help to reduce the amount of time that a patient spends within the care setting. An improvement in the level of communication within the care setting was also reported which again supports the findings of the Sweeney et al (2002) research.
The use of ICPs has been evaluated within other specialist units. Roberts et al (2004) assessed the effectiveness of ICP when used for elderly patients with femoral neck fractures. They found that it helped to improve the patients' clinical outcome. It was concluded from this that ICPs can be used in order to significantly improve care standards.
Therefore, it would appear from the research which has been reviewed in this discussion that ICPs have the potential advantages of reducing the length of time that a patient spends in a care setting, reduce costs, enable nurses to work in a more autonomous way, increase the number of relevant assessments which are performed, improve overall care standards and to improve the communication network present between the staff within the care setting. As with any evaluation, one needs to consider the disadvantages as well as these potential benefits. Some of the disadvantages of ICP have been highlighted within other relevant research.
4.1.2 EVIDENCE FOR THE DISADVANTAGES OF ICPs
Sulch et al (2002b) conducted a six month follow-up study involving 152 patients who required Stroke rehabilitation. It was found that the use of ICPs were associated with a lower quality of life for the patients relative to when MTD management is used. Conventional care methodologies were also found to promote more significant improvements in terms of the patient's functional ability, supporting the care giver, reducing the strain experienced by the care giver and improving social functioning. These appear to be significant drawbacks of using ICPs over conventional care methods. Clearly such findings would lead one to question the implementation of ICP. Another study by Sulch et al (2000) also reported that ICPs were no better than conventional care methods which were found to promote significantly faster improvements in terms of both the patients' quality of life and functional recovery. The potential disadvantages of ICP have been discussed with regards to other patient groups.
Roberts et al (2004) reported findings which contradicted some of the advantages outlined above. They found that the use of ICP led to the patients staying for a significantly longer period of time within the care setting. They also found that it was associated with a significantly higher use of therapy. Therefore, this would have an impact required on the resources which would be required if ICP approaches were to be implemented effectively. This discussion has demonstrated that the use of ICPs can be associated with the patients' spending more time in the care setting, a greater need for resources, a reduction in the patients' quality of life and functioning and a higher level of strain for the care giver.
In summary, the research evidence reviewed within the discussion has shown that ICPs can help to facilitate improved communications, increased patient assessments and more autonomy for nurses. It also has been shown to have the potential disadvantages of lower improvements in the patients' quality of life and functioning as well as placing more strain on the care giver. The research is less clear with reference to resources. Some research has indicated that it can reduce the time that patients spend in the care setting and also reduce the associated costs. However, other research has indicated that the patients may in fact need to stay in hospital for a longer period of time and to use other treatments, such as therapy, which means that more resources are required. Clearly, this is a complex issue which requires further research in order to assess the true resource implications of implementing ICPs.
In an age where the integration of the NHS, social care organisations and care delivery is non-negotiable, there is a potential role which could be played by ICPs. Many researchers and theorists in this field have advocated the use of ICPs to meet the challenge of an integrated approach to care (Riley 1998, Campbell et al 1998, Currie 1999). It has been suggested that care pathways can provide a mechanism through which continuous improvements can be made through traditional patient reviews (Wall et al 1998). The Commission for Health Improvements Reports had supported the development of ICPs as a recommended action. However, such recommendations need to be based on robust scientific research evidence. As a result of the time, effort and resources which is required to implement an ICP, it is of particular importance that the research evidence supporting such a move is analysed and evaluated.
It has previously been noted that there is a significant amount of anecdotal evidence available regarding ICPs (Johnson 1997, Zander 1992, Middleton et al 1998, De Luc 2001). However, beyond this there is a lack of objective research evidence in this area (Campbell et al 1998, Overill 1998, Currie 1999). The reported review has contributed to the knowledge within this research field by systematically reviewing studies which have evaluated the efficacy and effectiveness of ICPs. Inevitably, there are some significant advantages and disadvantages associated with this intervention along with some questions which merit further research and investigations. This discussion will now move on to consider the limitations which are associated with the methodology employed within this research as well as related topics which future research in this field need to address.
4.2 LIMITATIONS
Although all efforts were made to ensure that the methodology used within this study had scientific rigour, there are some ways in which it can be said to be limited. As was acknowledged in the method section of this report, the time and resources available to the researcher were limited. These constraints ensured that the size of the literature search and topic of interest needed to be tailored in order that they were appropriate for the time and resources available. Furthermore, whenever one is conducting a systematic literature search there is always the possibility that relevant research articles are missed. Although efforts were made to ensure that the search was both 'sensitive' and 'specific', one cannot ignore the possibility that appropriate research articles were not identified.
The exclusion criteria established within the methodology also provide some limitations of the project. The first exclusion criteria ensured that only research which involved evaluating ICPs was included within the research. This resulted in papers such AS Peters et al (2002) and Ellershaw et al (****) being excluded. This was because, although they were related to ICPs, they focussed upon their development or the setting of relevant standards rather than on evaluating its implementation. ?The second exclusion criteria ensured that no international research projects were included in this research. Therefore, research such as Johnson et al (2000), Bailey et al (1998) and Calligaro et al (1995) were excluded from the data set. They may well have contained information which was relevant to the research aim of this investigation and hence this constraint provides a limitation of the research. The final exclusion criteria set out within the methodology constrained the publications to be used to those published after 1998. It may be the case THAT the research published before this date could provide some relevant information and hence this restriction provides another limitation of this research.
4.3 FUTURE RESEARCH
There are many questions which remain unanswered regarding the use of ICPs. Future research needs to test whether or not the advantages and disadvantages of ICPs, which have been highlighted by this research, can be replicated within other specialist clinical areas. The majority of the relevant research has taken place within specialist areas. Subsequent research therefore needs to address the efficacy and effectiveness of ICPs within non-specific clinical areas. There are also a wide range of other factors which may have an influence on the success of ICPs and hence these need to be controlled for and assessed in terms of the significance associated with the role which they play. Such research would help to establish the circumstances in which ICPs are most feasible and effective. It would also investigate whether factors such as group dynamics, implementation strategy and the nature of the care setting have a significant impact. Further measures also need to be to investigated. For example, it would be interesting to research staff members' perceptions of ICP. The patients themselves could also be interviewed to determine their experience of their treatment and this could provide another data set upon which to evaluate ICPs. Clearly this research area is at the beginning of determining the possible role and effectiveness of ICPs. The advantages demonstrated by the researched reviewed within this discussion would lead one to conclude that ICPs have the potential to play an important role in achieving the Department of Health's aim to reform the health service in a way which is focussed on the individual and which provides a high quality services through the use of effective partnerships (Department of Health 2002).
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