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Comparative Study
. 2012 Jun 18:12:80.
doi: 10.1186/1471-2288-12-80.

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials

Thomas Rotter  1 , Leigh Kinsman, Erica James, Andreas Machotta, Ewout W Steyerberg
Affiliations
Comparative Study

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials

Thomas Rotter et al. BMC Med Res Methodol. .

Abstract

Background: The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs.

Methods: An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported.

Results: Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base.

Conclusions: Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.

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Figures

Figure 1
Figure 1
Simplified EPOC standard of study designs considered for inclusion in the present review. Source: Bero L, Eccles M, Grimshaw J, Gruen RL, Mayhew A, Oxman AD, Tavender E, Zwarenstein M, Shepperd S, Paulsen E, Pantoja T, Lewin S, Ballini L. Cochrane Effective Practice and Organisation of Care Group (Cochrane Group Module). About The Cochrane Collaboration (Cochrane Review Groups (CRGs)). The Cochrane Library. Oxford: John Wiley, 2009; adopted by the authors.
Figure 2
Figure 2
Trial flow.
Figure 3
Figure 3
Comparison meta analysis LOS COCHRANE vs. Excluded pre-post studies.
See this image and copyright information in PMC

References

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