Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an F test. For all statistical tests, p values of ≤ 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.
In recent years, health care payers and providers have found themselves under increasing pressure to improve quality and contain costs. Purchasers of health care services currently rely on a variety of mechanisms to achieve these goals; prospective payments, preauthorization for tests and procedures, and utilization review have all been used in attempts to control costs while maintaining or improving quality of care. 1 Responding to these trends, health care providers also have used various approaches to balance costs and quality, including implementation of practice standards and clinical guidelines.
Among these strategies, the concept of the clinical pathway has received considerable attention. Also known as the critical pathway, this methodology was originally developed by industrial engineers to define best practices and to outline timetables for completion of these tasks. 2 In the 1980s, Zander 3 and Grudich 4 advocated the adaptation and development of clinical pathways for health care as a means of improving patient outcomes while conserving resources. As currently defined, clinical pathways coordinate care for patients undergoing specific treatment interventions through use of a standardized, interdisciplinary process. Steps in this process are sequenced in a predetermined order to produce specific, desired outcomes within a set period of time. 5 By defining best practices and anticipated outcomes, pathways can contribute substantially to continuous quality improvement in patient care.
Clinical pathways have been developed and implemented for a variety of health care interventions, including caesarian section, 6 percutaneous transluminal coronary angioplasty, 7 burn treatment, 8 stroke management, 9 and pressure sores. 10 Because implementation of pathways requires commitment of considerable personnel time and institutional resources, pathway development to date has focused primarily on common, high-cost interventions. Pathways are not intended to be applied blindly to all patients within a treatment category. Rather, these processes are designed for average patients, with the expectation that 20 percent of patients will vary from the pathway. 5
As described by Gordon, 11 several steps are generally followed in the formulation and implementation of clinical pathways: (1) The focus/recognition phase sets goals for the proposed protocol and reviews the scientific literature to identify optimal techniques and outcomes. (2) The assessment and analysis phase identifies common treatment patterns and devises ways in which to improve practices. (3) In the development phase, a multidisciplinary patient care team refines the critical elements needed to achieve the desired outcomes. During this stage, mechanisms are also established to monitor the results of pathway implementation. (4) The final step is the implementation and evaluation phase in which the pathway is initiated. After implementation, variances and outcomes are studied and appropriate modifications are made in the pathway. As seen in these various phases, clinical pathway development and implementation are ongoing, iterative processes, which continue as long as the pathway remains in use.
Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly treatment intervention, we sought to devise, implement, and evaluate a clinical pathways program for this procedure at our institution. Specifically, our goal was to analyze the impact of a TRAM pathway on our resource utilization and quality of care associated with these reconstructions.