A clinical care pathway to improve the acute care of patients with glioma

Abstract

Background: Patients with glioma are at increased risk for tumor-related and treatment-related complications. Few guidelines exist to manage complications through supportive care. Our prior work suggests that a clinical care pathway can improve the care of patients with glioma.

Methods: We designed a quality improvement (QI) project to address the acute care needs of patients with gliomas. We formed a multidisciplinary team and selected 20 best-practice measures from the literature. Using a plan-do-study-act framework, we brainstormed and implemented various improvement strategies starting in October 2013. Statistical process control charts were used to assess progress.

Results: Retrospective data were available for 12 best practice measures. The baseline population consisted of 98 patients with glioma. Record review suggested wide variation in performance, with compliance ranging from 30% to 100%. The team hypothesized that lack of process standardization may contribute to less-than-ideal performance. After implementing improvement strategies, we reviewed the records of 63 consecutive patients with glioma. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre-QI; 76% post-QI, P > .1). Unexpectedly, a higher proportion of patients were readmitted within 30 days of hospital discharge (pre-QI: 10%; post-QI: 17%, P > .1). Barriers to pathway development included difficulties with transforming manual measures into electronic data sets.

Conclusions: Creating evidence-based clinical care pathways for addressing the acute care needs of patients with glioma is feasible and important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.

Keywords: glioma; outcomes; quality improvement.

Fig. 1.

Process flow map for the care of patients with glioma (postintervention phase). AD = advanced directive; Chemo = chemotherapy; EMR = electronic medical record; NCCC = Norris Cotton Cancer Center, Lebanon, NH; N/O = neuro-oncology; N/S = neurosurgery, Rehab = rehabilitation facility; RT = radiation oncology; SW = social worker; TAT = turn-around time. [cloud shaped image] summarize key changes that were made at the respective steps of the process.

Fig. 2.

Individual value and moving range (XmR) chart of percent standards of care achieved by patients with glioma pre- and post-quality improvement work, June 2011 – September 2013 and October 2013 – March 2015.^a,b CL = control limit, % = percent; QI = quality improvement. ^aCircle delineates a special cause event. ^bEach data point represents a single observation. Upper and lower control limits are set at 3-sigma to minimize the risk of a type I error.

Fig. 3.

Proportion of patients with glioma meeting criteria for individual best-practice measures pre- and post-quality improvement initiative, June 2011 – September 2013 and October 2013 – March 2015. AED = antiepileptic medications; F/u = follow-up; Neuro-Onc = Neuro-Oncology Program; post-op = postoperative; surg path = surgical pathology; VTE = venous-thromboembolic events. ^aP < .01. ^bP = .01. ^cP = .03. ^dP = .02.