Review of methods and study designs of evaluations related to clinical pathways
Xing Ju Lee A F , Robin Blythe A , Adnan Ali Khan Choudhury B C , Toni Simmons D E , Nicholas Graves A and Sanjeewa Kularatna A
+ Author Affiliations
- Author Affiliations
A Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia. Email: robin.blythe@qut.edu.au; n.graves@qut.edu.au; sanjeewa.kularatna@qut.edu.au
B Northern Queensland Primary Health Network, James Cook University, Building 500, 1 James Cook Drive, Douglas, Qld 4811, Australia. Email: adnan.choudhury@primaryhealth.com.au
C Australian Institute of Tropical Health and Medicine, James Cook University, Building 48, 1 James Cook Drive, Douglas Qld 4811, Australia.
D Mackay Hospital and Health Service, Mackay, 475 Bridge Road, Mackay, Qld 4740, Australia. Email: toni.simmons@health.qld.gov.au
E Mackay Institute of Research and Innovation, 475 Bridge Road, Mackay, Qld 4740, Australia.
F Corresponding author. Email: xj.lee@qut.edu.au
Australian Health Review 43(4) 448-456 https://doi.org/10.1071/AH17276
Submitted: 7 December 2017 Accepted: 19 May 2018 Published: 9 August 2018
Abstract
Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users’ experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation.
Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases.
Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings.
Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost–consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed.
What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited.
What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis.
What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.
Additional keywords: health services research, performance and evaluation.
References
[1] McGeoch G, McGeoch P, Shand B. Is HealthPathways effective? An online survey of hospital clinicians, general practitioners and practice nurses. N Z Med J 2015; 128 36–46.[2] Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med 2010; 8 31
| What is a clinical pathway? Development of a definition to inform the debate.Crossref | GoogleScholarGoogle Scholar |
[3] McGeoch G, Shand B. HealthPathways: some clarification. N Z Med J 2015; 128 65–6.
[4] Gray JS, Swan JR, Lynch MA, Tay TM, Mackenzie MJ, Wiggers JH, Harrison KA, McDonald RC, O’Dea IP, Harrigan LM, Fitzgerald SM, Hunter and New England HealthPathways Steering Committee Hunter and New England HealthPathways: a 4-year journey of integrated care. Aust Health Rev 2018; 42 66–71.
[5] Mansfield SJ, Quirk F, von Treuer K, Gill G. On the right path? Exploring the experiences and opinions of clinicians involved in developing and implementing HealthPathways Barwon. Aust Health Rev 2016; 40 129–35.
| On the right path? Exploring the experiences and opinions of clinicians involved in developing and implementing HealthPathways Barwon.Crossref | GoogleScholarGoogle Scholar |
[6] Robinson S, Varhol R, Bell C, Quirk F, Durrington L. HealthPathways: creating a pathway for health systems reform. Aust Health Rev 2015; 39 9–11.
| HealthPathways: creating a pathway for health systems reform.Crossref | GoogleScholarGoogle Scholar |
[7] Kenealy TW, Sheridan NF, Connolly MJ. HealthPathways website: making the right thing the easy thing to do? N Z Med J 2015; 128 6–9.
[8] Sanders AD, Stevenson C, Pearson J, Burt M, McGeoch G, Hudson B, Eglinton TW. A novel pathway for investigation of colorectal symptoms with colonoscopy or computed tomography colonography. N Z Med J 2013; 126 45–57.
[9] Canterbury District Health Board and Streamliners. Tying it all together – gynaecology case study. In ‘HealthPathways – For a connected system Information, Training and resource handbook for health organisations implementing the Whole-of-System approach and HealthPathways. Handbook from the Southern District Health Board Workshop, 15 March 2013, New Zealand.’ 2013. pp. 135–149.
[10] McGeoch GR, Sycamore MJ, Shand BI, Simcock JW. A regional programme to improve skin cancer management. J Prim Health Care 2015; 7 339–44.
| A regional programme to improve skin cancer management.Crossref | GoogleScholarGoogle Scholar |
[11] Short J, Sharp B, Elliot N, McEwing R, McGeoch G, Shand B, Holland K. Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding? Aust N Z J Obstet Gynaecol 2016; 56 432–5.
| Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding?Crossref | GoogleScholarGoogle Scholar |
[12] Stravens M, Short J, Johnson K, Simcock B, Shand B, McGeoch G, Sykes P. Management of postmenopausal bleeding by general practitioners in a community setting: an observational study. N Z Med J 2016; 129 59–68.
[13] Epton MJ, Kelly PT, Shand BI, Powell SV, Jones JN, McGeoch GR, Hlavac MC. Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand. NPJ Prim Care Respir Med 2017; 27 26
| Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand.Crossref | GoogleScholarGoogle Scholar |
[14] Holland K, McGeoch G, Gullery C. A multifaceted intervention to improve primary care radiology referral quality and value in Canterbury. N Z Med J 2017; 130 55–64.
[15] Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009; 6 e1000097
| Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.Crossref | GoogleScholarGoogle Scholar |
[16] Mackay T. Liver transplant assessment as same day admission. Transplant Nurses J 2004; 13 14–9.
[17] Lemberg DA, Day AS, Brydon M. The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis. Am J Med Qual 2005; 20 83–9.
| The role of a clinical pathway in curtailing unnecessary investigations in children with gastroenteritis.Crossref | GoogleScholarGoogle Scholar |
[18] Haxton J, Fahy K. Reducing length of stay for women who present as outpatients to delivery suite: a clinical practice improvement project. Women Birth 2009; 22 119–27.
| Reducing length of stay for women who present as outpatients to delivery suite: a clinical practice improvement project.Crossref | GoogleScholarGoogle Scholar |
[19] Topal B, Peeters G, Verbert A, Penninckx F. Outpatient laparoscopic cholecystectomy: clinical pathway implementation is efficient and cost effective and increases hospital bed capacity. Surg Endosc 2007; 21 1142–6.
| Outpatient laparoscopic cholecystectomy: clinical pathway implementation is efficient and cost effective and increases hospital bed capacity.Crossref | GoogleScholarGoogle Scholar |
[20] Wong C, Visram F, Cook DJ, Griffith L, Randall J, O’Brien B, Higgins D. Development, dissemination, implementation and evaluation of a clinical pathway for oxygen therapy. CMAJ 2000; 162 29–33.
[21] Deng Y, Jiao Y, Hu R, Wang Y, Wang Y, Zhao X. Reduction of length of stay and costs through the implementation of clinical pathways for stroke management in China. Stroke 2014; 45 e81–3.
| Reduction of length of stay and costs through the implementation of clinical pathways for stroke management in China.Crossref | GoogleScholarGoogle Scholar |
[22] He JA, Yang W. Clinical pathways in China – an evaluation. Int J Health Care Qual Assur 2015; 28 394–411.
| Clinical pathways in China – an evaluation.Crossref | GoogleScholarGoogle Scholar |
[23] Wang S, Zhu X, Zhao X, Lu Y, Yang Z, Qian X, Li W, Ma L, Guo H, Wang J, Wen A. DRUGS system improving the effects of clinical pathways: a systematic study. J Med Syst 2016; 40 59
| DRUGS system improving the effects of clinical pathways: a systematic study.Crossref | GoogleScholarGoogle Scholar |
[24] Zhao M, Yan Y, Yang N, Wang X, Tan F, Li J, Li J, Li X, Li G, Li J, Zhao Y, Cai Y. Evaluation of clinical pathway in acute ischemic stroke: a comparative study. Eur J Integr Med 2016; 8 169–75.
| Evaluation of clinical pathway in acute ischemic stroke: a comparative study.Crossref | GoogleScholarGoogle Scholar |
[25] Krummenauer F, Guenther KP, Kirschner S. Cost effectiveness of total knee arthroplasty from a health care providers’ perspective before and after introduction of an interdisciplinary clinical pathway – is investment always improvement? BMC Health Serv Res 2011; 11 338
| Cost effectiveness of total knee arthroplasty from a health care providers’ perspective before and after introduction of an interdisciplinary clinical pathway – is investment always improvement?Crossref | GoogleScholarGoogle Scholar |
[26] Holderried M, Hummel R, Falch C, Kirschniak A, Koenigsrainer A, Ernst C, Muller S. Compliance of clinical pathways in elective laparoscopic cholecystectomy: evaluation of different implementation methods. World J Surg 2016; 40 2888–91.
| Compliance of clinical pathways in elective laparoscopic cholecystectomy: evaluation of different implementation methods.Crossref | GoogleScholarGoogle Scholar |
[27] Panella M, Marchisio S, Di Stanislao F. Reducing clinical variations with clinical pathways: do pathways work? Int J Qual Health Care 2003; 15 509–21.
| Reducing clinical variations with clinical pathways: do pathways work?Crossref | GoogleScholarGoogle Scholar |
[28] Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T, Evaluation of Guidelines in Syncope Study 2 (EGSYS-2) Group Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace 2006; 8 644–50.
| Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals.Crossref | GoogleScholarGoogle Scholar |
[29] Marchisio S, Ferraccioli K, Barbieri A, Porcelli A, Panella M. Care pathways in obstetrics: the effectiveness in reducing the incidence of episiotomy in childbirth. J Nurs Manag 2006; 14 538–43.
| Care pathways in obstetrics: the effectiveness in reducing the incidence of episiotomy in childbirth.Crossref | GoogleScholarGoogle Scholar |
[30] Uchiyama K, Takifuji K, Tani M, Onishi H, Yamaue H. Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery. Surg Endosc 2002; 16 1594–7.
| Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery.Crossref | GoogleScholarGoogle Scholar |
[31] Yanagi K, Sasajima K, Miyamoto M, Suzuki S, Yokoyama T, Maruyama H, Matsutani T, Arima Y, Uchida E, Tajiri T. Evaluation of the clinical pathway for laparoscopic cholecystectomy and simulation of short-term hospitalization. J Nippon Med Sch 2007; 74 409–13.
| Evaluation of the clinical pathway for laparoscopic cholecystectomy and simulation of short-term hospitalization.Crossref | GoogleScholarGoogle Scholar |
[32] Brunenberg DE, van Steyn MJ, Sluimer JC, Bekebrede LL, Bulstra SK, Joore MA. Joint recovery programme versus usual care: an economic evaluation of a clinical pathway for joint replacement surgery. Med Care 2005; 43 1018–26.
| Joint recovery programme versus usual care: an economic evaluation of a clinical pathway for joint replacement surgery.Crossref | GoogleScholarGoogle Scholar |
[33] Andriessen PA, Polignano R, Abel M. Development and implementation of a clinical pathway to improve venous leg ulcer treatment. Wounds 2009; 21 127–33.
[34] Khowaja K. Utilization of King’s interacting systems framework and theory of goal attainment with new multidisciplinary model: clinical pathway. Aust J Adv Nurs 2006; 24 44–50.
[35] Soria V, Pellicer E, Flores B, Carrasco M, Candel MF, Aguayo JL. Evaluation of the clinical pathway for laparoscopic cholecystectomy. Am Surg 2005; 71 40–5.
[36] Campillo-Soto Á, Martín-Lorenzo JG, Lirón-Ruíz R, Torralba-Martínez JA, Bento-Gerard M, Flores-Pastor B, Aguayo-Albasini JL. Evaluation of the clinical pathway for laparoscopic bariatric surgery. Obes Surg 2008; 18 395–400.
| Evaluation of the clinical pathway for laparoscopic bariatric surgery.Crossref | GoogleScholarGoogle Scholar |
[37] Soria-Aledo V, Flores-Pastor B, Candel-Arenas MF, Carrillo-Alcaraz A, Campillo-Soto Á, Miguel-Perelló J, Carrasco Prats M, Aguayo-Albasini JL. Evaluation and monitoring of the clinical pathway for thyroidectomy. Am Surg 2008; 74 29–36.
[38] Verdú A, Maestre A, López P, Gil V, Martín-Hidalgo A, Castaño JA. Clinical pathways as a healthcare tool: design, implementation and assessment of a clinical pathway for lower-extremity deep venous thrombosis. Qual Saf Health Care 2009; 18 314–20.
| Clinical pathways as a healthcare tool: design, implementation and assessment of a clinical pathway for lower-extremity deep venous thrombosis.Crossref | GoogleScholarGoogle Scholar |
[39] Müller MK, Dedes KJ, Dindo D, Steiner S, Hahnloser D, Clavien PA. Impact of clinical pathways in surgery. Langenbecks Arch Surg 2009; 394 31–9.
| Impact of clinical pathways in surgery.Crossref | GoogleScholarGoogle Scholar |
[40] Lee SC, Tseng HY, Wang KY, Lee LC. Effect of a clinical pathway on selected clinical outcomes of pulmonary lobectomy. Chin Med J (Engl) 2002; 65 7–12.
[41] Lee TY, Chan T, Chang CS, Lan JL. Introducing a clinical pathway for acute peptic ulcer bleeding in general internal medicine wards. Scand J Gastroenterol 2008; 43 1169–76.
| Introducing a clinical pathway for acute peptic ulcer bleeding in general internal medicine wards.Crossref | GoogleScholarGoogle Scholar |
[42] Hadwin R, Eggington S, Brennan A, Walker P, Patnick J, Pilgrim H. Modelling the cost-effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK cervical screening programme. BJOG 2008; 115 749–57.
| Modelling the cost-effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK cervical screening programme.Crossref | GoogleScholarGoogle Scholar |
[43] Halley HJ. Approaches to drug therapy, formulary, and pathway management in a large community hospital. Am J Health Syst Pharm 2000; 57 S17–21.
[44] Hwang TG, Wilkins EG, Lowery JC, Gentile J. Implementation and evaluation of a clinical pathway for TRAM breast reconstruction. Plast Reconstr Surg 2000; 105 541–8.
| Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.Crossref | GoogleScholarGoogle Scholar |
[45] Levin RJ, Ferraro RE, Kodosky SR, Fedok FG. The effectiveness of a ‘critical pathway’ in the management of laryngectomy patients. Head Neck 2000; 22 694–9.
| The effectiveness of a ‘critical pathway’ in the management of laryngectomy patients.Crossref | GoogleScholarGoogle Scholar |
[46] Lewis CK. A performance improvement initiative: development of a peripheral vascular pathway. J Vasc Nurs 2000; 18 13–19.
| A performance improvement initiative: development of a peripheral vascular pathway.Crossref | GoogleScholarGoogle Scholar |
[47] Wee AS, Cooper WB, Chatham RK, Cobb AB, Murphy T. The development of a stroke clinical pathway: an experience in a medium-sized community hospital. J Miss State Med Assoc 2000; 41 648–53.
[48] Calland JF, Tanaka K, Foley E, Bovbjerg VE, Markey DW, Blome S, Minasi JS, Hanks JB, Moore MM, Young JS, Jones RS, Schirmer BD, Adams RB. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg 2001; 233 704–15.
| Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.Crossref | GoogleScholarGoogle Scholar |
[49] McIlvoy L, Spain DA, Raque G, Vitaz T, Boaz P, Meyer K. Successful incorporation of the severe head injury guidelines into a phased-outcome clinical pathway. J Neurosci Nurs 2001; 33 72–82.
| Successful incorporation of the severe head injury guidelines into a phased-outcome clinical pathway.Crossref | GoogleScholarGoogle Scholar |
[50] Vitaz TW, McIlvoy L, Raque GH, Spain D, Shields CB. Development and implementation of a clinical pathway for severe traumatic brain injury. J Trauma 2001; 51 369–75.
| Development and implementation of a clinical pathway for severe traumatic brain injury.Crossref | GoogleScholarGoogle Scholar |
[51] Vitaz TW, McIlvoy L, Raque GH, Spain DA, Shields CB. Development and implementation of a clinical pathway for spinal cord injuries. J Spinal Disord 2001; 14 271–6.
| Development and implementation of a clinical pathway for spinal cord injuries.Crossref | GoogleScholarGoogle Scholar |
[52] Wazeka A, Valacer DJ, Cooper M, Caplan Mary DiMaio DW. Impact of a pediatric asthma clinical pathway on hospital cost and length of stay. Pediatr Pulmonol 2001; 32 211–6.
| Impact of a pediatric asthma clinical pathway on hospital cost and length of stay.Crossref | GoogleScholarGoogle Scholar |
[53] DeSomma M, Divekar A, Galloway AC, Colvin SB, Artman M, Auslender M. Clinical methods. Impact of a clinical pathway on the postoperative care of children undergoing surgical closure of atrial septal defects. Appl Nurs Res 2002; 15 243–8.
| Clinical methods. Impact of a clinical pathway on the postoperative care of children undergoing surgical closure of atrial septal defects.Crossref | GoogleScholarGoogle Scholar |
[54] Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg Am 2002; 84 348–53.
| Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty.Crossref | GoogleScholarGoogle Scholar |
[55] Melbert RB, Kimmins MH, Isler JT, Billingham RP, Lawton D, Salvadalena G, Cortezzo M, Rowbotham R. Use of a critical pathway for colon resections. J Gastrointest Surg 2002; 6 745–52.
| Use of a critical pathway for colon resections.Crossref | GoogleScholarGoogle Scholar |
[56] Michalsky MP, Pratt D, Caniano DA, Teich S. Streamlining the care of patients with hypertrophic pyloric stenosis: application of a clinical pathway. J Pediatr Surg 2002; 37 1072–5.
| Streamlining the care of patients with hypertrophic pyloric stenosis: application of a clinical pathway.Crossref | GoogleScholarGoogle Scholar |
[57] Wilson SD, Dahl BB, Wells RD. An evidence-based clinical pathway for bronchiolitis safely reduces antibiotic overuse. Am J Med Qual 2002; 17 195–9.
| An evidence-based clinical pathway for bronchiolitis safely reduces antibiotic overuse.Crossref | GoogleScholarGoogle Scholar |
[58] Burns SM, Earven S, Fisher C, Lewis R, Merrell P, Schubart JR, Truwit JD, Bleck TP, University of Virginia Long Term Mechanical Ventilation Team Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med 2003; 31 2752–63.
| Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned.Crossref | GoogleScholarGoogle Scholar |
[59] Ranjan A, Tarigopula L, Srivastava RK, Obasanjo OO, Obah E. Effectiveness of the clinical pathway in the management of congestive heart failure. South Med J 2003; 96 661–3.
| Effectiveness of the clinical pathway in the management of congestive heart failure.Crossref | GoogleScholarGoogle Scholar |
[60] Holden WE, Lewinsohn DM, Osborne ML, Griffin C, Spencer A, Duncan C, Deffebach ME. Use of a clinical pathway to manage unsuspected radiographic findings. Chest 2004; 125 1753–60.
| Use of a clinical pathway to manage unsuspected radiographic findings.Crossref | GoogleScholarGoogle Scholar |
[61] Campbell MA. Development of a clinical pathway for near-term and convalescing premature infants in a Level II nursery. Adv Neonatal Care 2006; 6 150–64.
| Development of a clinical pathway for near-term and convalescing premature infants in a Level II nursery.Crossref | GoogleScholarGoogle Scholar |
[62] Ho DM, Huo MH. Are critical pathways and implant standardization programs effective in reducing costs in total knee replacement operations? J Am Coll Surg 2007; 205 97–100.
| Are critical pathways and implant standardization programs effective in reducing costs in total knee replacement operations?Crossref | GoogleScholarGoogle Scholar |
[63] Walter FL, Bass N, Bock G, Markel DC. Success of clinical pathways for total joint arthroplasty in a community hospital. Clin Orthop Relat Res 2007; 133–7.
[64] Santillan A, Govan L, Zahurak ML, Diaz-Montes TP, Giuntoli RL, Bristow RE. Feasibility and economic impact of a clinical pathway for pap test utilization in gynecologic oncology practice. Gynecol Oncol 2008; 109 388–93.
| Feasibility and economic impact of a clinical pathway for pap test utilization in gynecologic oncology practice.Crossref | GoogleScholarGoogle Scholar |
[65] Nicasio AM, Eagye KJ, Kuti EL, Nicolau DP, Kuti JL. Length of stay and hospital costs associated with a pharmacodynamic-based clinical pathway for empiric antibiotic choice for ventilator-associated pneumonia. Pharmacotherapy 2010; 30 453–62.
| Length of stay and hospital costs associated with a pharmacodynamic-based clinical pathway for empiric antibiotic choice for ventilator-associated pneumonia.Crossref | GoogleScholarGoogle Scholar |
[66] Hoverman JR, Cartwright TH, Patt DA, Espirito JL, Clayton MP, Garey JS, Kopp TJ, Kolodziej M, Neubauer MA, Fitch K, Pyenson B, Beveridge RA. Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases. J Oncol Pract 2011; 7 52s–9s.
| Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases.Crossref | GoogleScholarGoogle Scholar |
[67] Duncan CM, Moeschler SM, Horlocker TT, Hanssen AD, Hebl JR. A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty. Reg Anesth Pain Med 2013; 38 533–8.
| A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty.Crossref | GoogleScholarGoogle Scholar |
[68] Kreys ED, Koeller JM. Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer’s perspective. J Oncol Pract 2013; 9 e241–7.
| Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer’s perspective.Crossref | GoogleScholarGoogle Scholar |
[69] Pershad J, Waters TM, Langham MR, Li T, Huang EY. Cost-effectiveness of diagnostic approaches to suspected appendicitis in children. J Am Coll Surg 2015; 220 738–46.
| Cost-effectiveness of diagnostic approaches to suspected appendicitis in children.Crossref | GoogleScholarGoogle Scholar |
[70] Rutman L, Atkins RC, Migita R, Foti J, Spencer S, Lion KC, Wright DR, Leu MG, Zhou C, Mangione-Smith R. Modification of an established pediatric asthma pathway improves evidence-based, efficient care. Pediatrics 2016; 138 e20161248
| Modification of an established pediatric asthma pathway improves evidence-based, efficient care.Crossref | GoogleScholarGoogle Scholar |
[71] Klein D, Campbell A. The CQI pathway. Rehab Manag 1995; 8 89–92, 94–5.
[72] Schumacher M, Allignol A, Beyersmann J, Binder N, Wolkewitz M. Hospital-acquired infections – appropriate statistical treatment is urgently needed! Int J Epidemiol 2013; 42 1502–8.
| Hospital-acquired infections – appropriate statistical treatment is urgently needed!Crossref | GoogleScholarGoogle Scholar |
