Standardized Clinical Pathways for Hospitalized Children and Outcomes

Abstract

Background and objective: Clinical pathways standardize care for common health conditions. We sought to assess whether institution-wide implementation of multiple standardized pathways was associated with changes in utilization and physical functioning after discharge among pediatric inpatients.

Methods: Interrupted time series analysis of admissions to a tertiary care children's hospital from December 1, 2009 through March 30, 2014. On the basis of diagnosis codes, included admissions were eligible for 1 of 15 clinical pathways implemented during the study period; admissions from both before and after implementation were included. Postdischarge physical functioning improvement was assessed with the Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales. Average hospitalization costs, length of stay, readmissions, and physical functioning improvement scores were calculated by month relative to pathway implementation. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation.

Results: There were 3808 and 2902 admissions in the pre- and postpathway groups, respectively. Compared with prepathway care, postpathway care was associated with a significant halt in rising costs (prepathway vs postpathway slope difference -$155 per month [95% confidence interval -$246 to -$64]; P = .001) and significantly decreased length of stay (prepathway vs post-pathway slope difference -0.03 days per month [95% confidence interval -0.05 to -0.02]; P = .02), without negatively affecting patient physical functioning improvement or readmissions.

Conclusions: Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively affecting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.

FIGURE 1

Numbers of admissions and study months before and after pathway implementation, by pathway. Date of pathway implementation is indicated next to the pathway name. A, Numbers of admissions meeting pathway criteria, before and after each pathway was implemented. B, Number of months included in study by pathway, before and after implementation. *Inclusion criteria for this pathway depends on clinical documentation of fever, which was not available in the electronic medical record until February 2012, which is why there are fewer months of data for this pathway than others. DKA, diabetic ketoacidosis.

FIGURE 2

Interrupted time series analysis results for costs of hospitalization and LOS, before and after implementation of pathways. Pathway implementation is denoted by the dashed center line. A, Monthly average hospital costs per admission in 2013 US dollars. B, Monthly average LOS in days. All estimates are followed by 95% CIs in parentheses. ^aIntercept represents the y-intercept for each time period–specific regression line. ^bSlope is the slope for each time period–specific regression line, which indicates the change in outcome by month over the study period. For example, the prepathway cost regression line has a slope of +126, meaning average per-patient costs were increasing by $126 per month during the prepathway period. ^cDifference between pre- and postpathway period slopes is the calculated difference in time period–specific slopes, indicating the change from the trajectory established during the prepathway period to the trajectory observed during the postpathway period. P value indicates whether the 2 slopes are statistically different from one another. ^dDifference between pre-and postpathway period intercepts is the calculated difference in time period–specific intercepts, indicated the mean value for the outcome at the beginning of the time period. When no significant slope exists during the time period, the intercept is equal to the mean value for the time period.

FIGURE 3

Interrupted time series analysis results for readmissions and physical functioning improvement scores, before and after implementation of pathways. Pathway implementation is denoted by the dashed center line. A, Monthly average unplanned hospital readmissions within 30 days of index admission. B, Monthly average physical functioning improvement scores, calculated as score at follow-up minus score at hospital admission. All estimates are followed by 95% CIs in parentheses. ^aIntercept represents the y-intercept for each time period–specific regression line. ^bSlope is the slope for each time period–specific regression line, which indicates the change in outcome by month over the study period. For example, the prepathway cost regression line has a slope of +126, meaning average per-patient costs were increasing by $126 per month during the prepathway period. ^cDifference between pre- and postpathway period slopes is the calculated difference in time period–specific slopes, indicating the change from the trajectory established during the prepathway period to the trajectory observed during the postpathway period. The P value indicates whether the 2 slopes are statistically different from one another. ^dDifference between pre- and postpathway period intercepts is the calculated difference in time period–specific intercepts, indicated the mean value for the outcome at the beginning of the time period. When no significant slope exists during the time period, the intercept is equal to the mean value for the time period.