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Meta-Analysis
. 2008 Dec 19:8:265.
doi: 10.1186/1472-6963-8-265.

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

Thomas Rotter  1 , Joachim Kugler, Rainer Koch, Holger Gothe, Sabine Twork, Jeroen M van Oostrum, Ewout W Steyerberg
Affiliations
Meta-Analysis

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes

Thomas Rotter et al. BMC Health Serv Res. .

Abstract

Background: To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy.

Methods: As participants, we considered hospitalized children and adults of every age and indication whose treatment involved the management strategy "clinical pathways". We include only randomised controlled trials (RCT) and controlled clinical trials (CCT), not restricted by language or country of publication. Single measures of continuous and dichotomous study outcomes were extracted from each study. Separate analyses were done in order to compare effects of clinical pathways on length of stay (LOS), hospital costs and patient outcomes. A random effects meta-analysis was performed with untransformed and log transformed outcomes.

Results: In total 17 trials met inclusion criteria, representing 4,070 patients. The quality of the included studies was moderate and studies reporting economic data can be described by a very limited scope of evaluation. In general, the majority of studies reporting economic data (LOS and hospital costs) showed a positive impact. Out of 16 reporting effects on LOS, 12 found significant shortening. Furthermore, in a subgroup-analysis, clinical pathways for invasive procedures showed a stronger LOS reduction (weighted mean difference (WMD) -2.5 days versus -0.8 days)).There was no evidence of differences in readmission to hospitals or in-hospital complications. The overall Odds Ratio (OR) for re-admission was 1.1 (95% CI: 0.57 to 2.08) and for in-hospital complications, the overall OR was 0.7 (95% CI: 0.49 to 1.0). Six studies examined costs, and four showed significantly lower costs for the pathway group. However, heterogeneity between studies reporting on LOS and cost effects was substantial.

Conclusion: As a result of the relatively small number of studies meeting inclusion criteria, this evidence base is not conclusive enough to provide a replicable framework for all pathway strategies. Considering the clinical areas for implementation, clinical pathways seem to be effective especially for invasive care. When implementing clinical pathways, the decision makers need to consider the benefits and costs under different circumstances (e.g. market forces).

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Figures

Figure 1
Figure 1
Identification of relevant studies/trail flow. [see attached file 1] (PDF Format).
Figure 2
Figure 2
Electronic search results. [see attached file 2] (PDF Format).
Figure 3
Figure 3
Effects on LOS. [see attached file 3] (BMP Format).
Figure 4
Figure 4
Effects on in-hospital complications. [see attached file 4] (BMP Format).
Figure 5
Figure 5
Effects on re-hospitalisation. [see attached file 5] (BMP Format).
Figure 6
Figure 6
Effects on LOS invasive pathways. [see attached file 6] (BMP Format).
Figure 7
Figure 7
Effects on LOS non-invasive pathways. [see attached file 7] (BMP Format).
Figure 8
Figure 8
Funnel plot analyses. [see attached file 8] (BMP Format).
Figure 9
Figure 9
a & b – Graphic distribution original cpw data and LN transformed. [see attached file 9 a & b] (PDF Format).
See this image and copyright information in PMC

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