# Development of a Model Care Pathway for Myasthenia Gravis
## 4 Discussion  
The development of CPs is a process that starts incorporating the best medical literature into clinical practice [66]. Often, several guidelines are produced for the most common diseases, frequently presenting conflicting evidence [67]. Therefore, selecting the most appropriate evidence to be included in CPs can be complex [68]. This is also a continuous process because medical literature is continuously updated, and CPs need to be updated accordingly [69]. When developing the CP for MG, our findings showed a different scenario. In fact, the number of clinical practice guidelines published for MG during the last ten years was significantly lower than the similar disease condition [70,71] and most of them are presented same similar clinical contents. Usually, core activities are based on the strongest evidence [72]. This was not the case for MG, because only a few of the core activities were derived from class-A evidence, whereas most of them were based on expert opinion. This could be a critical problem when implementing operational care pathways(b) locally, because local teams should consider that they are incorporating expert opinion rather than objective data into their clinical practice, and after the implementation professionals tend not to consider any more the original quality of the evidences [73]. In our study, there was a high level of agreement between experts both for the completeness of the newly developed model pathway (process flow) and for the appropriateness of the included clinical/care activities, regardless of their LOE (class-A, B, and C evidence). Even if we cannot conclude that the experts gave the same value to practices based on opinions more than on evidence, again we think that this issue could affect the quality of local CPs. Therefore, we believe that the relationship between the objective level of evidence and how they are perceived by healthcare professionals should be further studied in other settings. The largest variation in experts' opinions was around the settings for carrying out the diagnostic activities and for the patients' treatment. In the United States, these processes were mainly based in ambulatory settings, whereas in Europe they were executed generally in hospitals. We can reasonably assume that the observed differences reflect the different models of the healthcare systems (private vs. public) [74,75], as it has been also shown in the studies measuring variations in the costs for the treatment of MG patients [76]. Since the local implementation of CPs combines the most appropriate care with the most appropriate use of resources, this could be a further critical issue for applying the MG model CP in real life [77,78]. Teamwork is a key component for the successful implementation of CPs [79, 80, 81]. To better organise their work, CP teams need information on performance of their core processes before and after implementation of the CPs [35]. Therefore, an effective model care pathway(a) should also include the most appropriate metrics, process performance, and/or quality indicators derived from the literature [82]. In general, such core performance measures already exist in the medical literature [40,41]. This was not the case when looking for the core performance measures for MG. Therefore, we autonomously developed new quality indicators and metrics. This development process was driven by the information gathered from the experts, adopting a model that combined the importance of each process with the related risk of bottlenecks and/or its expected impact on patients' outcomes. Even if we adopted a rigorous process design, nevertheless our indicators have not been validated yet. This is a further major limitation for the future implementation of the operational CPs for MG. Therefore, we draft a study to test the validity and the generalizability of the set of core performance measures and quality indicators. * Model CP: The model care pathway is based on the available international and national evidence. It is not specific to any organization.