Critical pathways: what do you do when they do not seem to work?

The pressure to improve quality of patient care and reduce health care costs has increased in recent years. To add to existing concerns about the quality of health care, the Institute of Medicine has estimated that between 44,000 and 98,000 people die each year from medical errors and that these errors could be the fifth to eighth leading cause of death in the United States (1). In addition, a recent study showed widespread underuse of potentially life saving treatments among Medicare beneficiaries in every state in the nation (2). To remedy the situation, national and international attention has focused on efforts to influence and improve quality of care, and the creation and implementation of critical pathways has become a popular response to these concerns in hospitals (3). The rationale for creating critical pathways is that there are certain tasks that are routinely performed in managing the care of hospitalized patients (3). Care may become more efficient if key aspects of clinical care are systematically expressed in a time and task matrix model, and that model is used to guide the care of patients. Experiences in industries other than health care suggests that this approach can improve efficiency (3). In the current issue of the Green Journal, Pearson et al (4) report an important investigation from the Brigham and Women’s Hospitals, in which critical pathways were implemented and evaluated for surgical conditions. The authors found minimal improvements in the processes of care or mortality rates attributable to the critical pathways (4). There were significant reductions in lengths of stay, but the reductions were similar to those at health care organizations at which there were no organized critical pathway efforts in place. Therefore, the critical pathway program was responsible for very modest improvements in patient care, and was probably without a measurable “return on investment.” These results occurred in an organization where the investigators are extremely knowledgeable and experienced in the field of critical pathways (3). How does an organization respond when a medical management effort has been evaluated and demonstrated to have minimal benefit? The authors state “The critical pathways we studied are still in use at Brigham and Women’s Hospital and are updated periodically. However, plans to develop pathways for other conditions have been dropped.” Is this an appropriate response given their research findings? When critical pathways are not associated with measurable benefit, should they be maintained, or abandoned with resources redirected to other strategies that could prove to be more effective? This study highlights the importance of rigorously evaluating critical pathways and medical management approaches. Only after the authors observed declining lengths of stay in organizations without critical pathways did they believe that the reductions at their organization were more likely to be a result of secular trends rather than the critical pathways. Many organizations, especially those that do not evaluate general trends in lengths of stay, may have incorrectly concluded that lengths of stay declined as a result of critical pathways and would have been tempted to broaden the scope of their critical pathway program based on their findings. Similar observations have occurred in the evaluation of medical management strategies. An evaluation of a continuous quality improvement and critical pathway program for patients undergoing cardiac surgery in New England demonstrated a 24% reduction in mortality, which could translate into saved thousands of lives annually if the quality improvement program was implemented nationally (5). However, another study showed that mortality rates were reduced by 25% in neighboring states without any formal statewide or regional quality improvement and critical pathway efforts (6). When taken together, these studies suggest that there were no conclusive improvements in care for patients undergoing cardiac surgery attributable to the quality improvement programs. How should health care organizations respond to medical management efforts, such as critical pathways, when they have not been shown to improve care? The answer depends on the risks, costs, and opportunity costs of continuing to implement critical pathways or other strategies. It has been assumed that critical pathways are not associated with risk, although there are relatively few studies to support or refute that belief. However, critical pathways are costly to develop, update, and implement. There may also be opportunity costs of not pursuing other strategies that might more effectively improve quality, reduce costs, and enhance patient safety, since these other strategies must compete for organizational resources. Am J Med. 2001;110:224 –225. From the Cedars-Sinai Health System, University of California, Los Angeles, School of Medicine, and Zynx Health, Inc., Beverly Hills, California. Requests for reprints should be addressed to Scott Weingarten, MD, MPH, Cedars-Sinai Medical Center, Department of Health Services Research and Medicine, 200 North Robertson Boulevard, Suite 205, Beverly Hills, California 90211.