Goals, Design, and Implementation of Critical Pathways in Cardiovascular Medicine
Christopher P. Cannon
Patrick T. O’Gara
With the numerous advances in all areas of medical science, the practice of medicine has become very complex and specialized. Each condition, fortunately, has many different tests that can help characterize the disease prognosis and sometimes even help in selecting treatment. Among the treatments, many exist, but registries of current practice repeatedly show underutilization of many lifesaving medications. Accordingly, a major focus of nearly every physician and health care group, including many governmental agencies, has been to try to improve appropriate use of medications and treatments. All this is especially true in cardiovascular medicine, where multiple lifesaving treatments exist for patients, but where underutilization is widespread, ironically in the highest-risk patients.
One approach to improving the practice of medicine has been the use of “critical pathways,” which are standardized protocols for the management of specific disorders that aim to optimize and streamline patient care. Numerous other names have been developed for such programs, including “clinical pathways” (so as not to suggest to patients that they are in “critical” condition), or simply “protocols,” such as acute ST-elevation myocardial infarction (STEMI) protocols used in emergency departments (EDs) to reduce time to treatment with thrombolysis (1,2). A broader name of “disease management” is currently used to denote that these pathways extend beyond the hospital phase of treatment to optimize medical management over the long term.
The complexity of the pathways has also been used to distinguish true “critical pathways” (e.g., coronary artery bypass surgery pathways) as tools that detail the processes of care and potential inefficiencies, from “clinical protocols,” which are algorithms and treatment recommendations focused on improving compliance with “evidence-based” medicine. Different disease states lend themselves to more complex pathways, such as those that exist for coronary artery bypass surgery. In contrast, for medical conditions in which patients are treated as outpatients, such as hypertension or hypercholesterolemia, the critical pathways tend to be more algorithm-based documents. Notwithstanding these minor differences in terminology, a broader view of “critical pathways” is adopted in this book, where various types of pathways are presented by leading clinicians to summarize current state-of-the-art cardiovascular practice.
Goals of Critical Pathways
The use of critical pathways initially emerged from the interest of hospital administrators as a means to reduce length of hospital stay. However, clinicians have recognized many other goals for such pathways, the most important of which is the need to improve the quality of patient care (Table 1-1). Indeed, physicians involved in developing critical pathways should focus on the positive aspects of pathways and utilize them as a means to advance medical care. Other specific goals focus on (a) improving the use of medications and treatments, (b) improving patient triage to the appropriate level of care (1,34,5), (c) increasing participation in research protocols, and (d) limiting the use of unnecessary tests to reduce costs and allow savings to be allocated to other treatments that have been shown to be beneficial. With involvement of physicians, nurses, and other clinicians in the development of these pathways, those responsible for patient care can control how the patients are managed. Indeed, it is important to monitor their performance of pathways and to ensure that they are up to date with new advances in care.
Table 1-1. Goals of Critical Pathways | |
|---|---|
|
Need and Rationale for Critical Pathways
Despite wide dissemination of the clinical trial results, a large proportion of patients with acute coronary syndromes do not receive “evidence-based” medical therapies. Such a glaring deficiency has been seen most dramatically for aspirin (6,7,8,9,10,11,12,13), but it is also apparent with the use of thrombolytic therapy (10,14,15), beta-blockers (16), statins (8,17), and many other classes of drugs.
Another need addressed by critical pathways is the marked variation in the use of cardiac procedures following admission for acute MI and unstable angina. In acute MI, numerous studies have found wide differences in the use of invasive cardiac procedures but no differences in mortality (18,19,20,21), suggesting that some of these procedures may be unnecessary or inappropriate.
Other areas of potential overutilization of testing also exist (e.g., with laboratory tests and echocardiography) (22,23,24). Several studies have suggested that for patients with small non-Q wave MIs, assessment of LV function via echocardiography or ventriculography may not be necessary, a strategy that could have potential implications for more cost-effective care.
Reducing Hospital (and ICU) Length of Stay
Reduction in hospital length of stay has been the driving force behind the creation of critical pathways. As noted in the initial pathways for cardiac surgical patients, early discharge was the main outcome variable (25). In acute coronary syndromes, length of stay was quite long in the 1990s, where it was 9 days for patients with unstable angina and non-STEMI (UA/NSTEMI) (26) and in STEMI (27), even among patients who had an uncomplicated course (13). Over the subsequent decade, however, length of stay has steadily decreased (28), showing that this has been one way to improve efficiency of care.
Overutilization of Intensive Care
Overutilization of the intensive and coronary care unit (CCU) is another area in which critical pathways may reduce costs. In the 1980s and early 1990s, admission to the coronary care unit was standard for all unstable angina and MI (and frequently “rule out MI”) patients (29,30). Even in 1996, 40% of patients with UA/NSTEMI in the multicenter GUARANTEE Registry conducted in the United States were admitted to the CCU (31). Because CCU admission is now generally recommended for higher-risk patients (i.e., those with STEMI and/or hemodynamic compromise or other complications), such data suggest opportunities may exist for reducing the number of patients admitted to intensive care units.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
