The Design and Evaluation of Clinical Pathway for Disease Management to Maximize Public Health Benefit

Abstract

As an implementation strategy, the actual functional scope of clinical pathway (CPW) can be mastered is the basis for evaluating and improving CPW management, which is very important for bridging the evidence-to-practice gap. Here, we propose and discuss a design and evaluation model for CPWs through some theoretical lenses that may help the designer master the actual functional scope of CPWs and accumulate and refine effective key management steps of a specific disease. We can thus determine the best-optimized design with the largest net benefit that allows definition of the core management steps for a specific disease.

Keywords: clinical pathway; evidence-based medicine; health technology assessment; implementation science; public health economics.

Figure 1

Pathway design and evaluation programme. The process is repeated until the clinical pathway management design achieves the maximum public health benefit.

Figure 2

(A) Levels of changes in healthcare quality and corresponding improvement efforts. (B) Two dimensions to define the actual functional scope of clinical pathways (CPWs).

Figure 3

(A) Generation of pathway elements and pathway design construction. Taking the clinical pathway for neonatal hypoglycaemia management with rooming-in at a hospital as a hypothetical example, “initial feed within 1 hour and screen plasma glucose 30 minutes after 1st feed” generates critical pathway elements because it is the proven key decision-making step in terms of whole costs and benefits for neonatal hypoglycaemia management with rooming-in. For low blood glucose concentrations that may occur in the first hours after birth or persist for up to several days, the duration of screening plasma glucose prior to each feed and its impact on the whole costs and benefits of neonatal hypoglycaemia management are uncertain. Thus, “Continue feeds q 2–3 hours and screen plasma glucose prior to each feed until 24 hours” generates controversial pathway elements. The other interventions are the standard operating procedures; they generate conventional pathway elements. Each pathway element is constructed by population (pathway node) and intervention (pathway node branch), and interlocking pathway elements ultimately form the pathway prototype. (B) Full-chain trajectory tracking and data collection after a patient enters the pathway. The design of pathway nodes is based on core characteristics and clinical outcomes of the population, and each pathway node is given a unique node code, ie, a, b, c … …. After a patient enters the pathway, the trajectory code is the chronological arrangement of the node code corresponding to the core features and the patient’s clinical outcomes after entering the pathway. For example, 20 newborns stop at node c, their trajectory codes are “ac”, 99 newborns stop at node h, and their trajectory codes are “acfh”. Using these trajectory codes, all patients’ diagnosis and treatment procedure data can be collected and integrated to visualize the pathway’s actual operating process.

Figure 4

Determination of the current optimal pathway design scheme according to the marginal benefit (incremental gain) and marginal cost (incremental cost). (A) The relationship between marginal benefit and marginal cost and their changes as the CPW design improves. (B) The relationship between the total benefit and total cost of CPW management and their changes as the CPW design improves.

Figure 5

The external evaluation research plan with stepwise evaluations of and improvements in pathway design.