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Critical pathways reduce postoperative hospital stays no more than local market forces

Step-by-step guides to caring for patients with certain conditions, so-called critical pathways, are often used to make care more standardized and efficient. Several studies have shown that such an approach may reduce postoperative hospital stays, but the studies had methodological shortcomings.

A recent study supported by the Agency for Healthcare Research and Quality (HS08311) found that critical pathways, which were developed and implemented at one hospital following a substantial investment of time and effort, led to significant reductions in postoperative hospital stays for five types of surgery. However, the researchers also found comparable, often dramatic reductions in length of stay at neighboring hospitals that did not launch critical pathways or other specific efficiency initiatives.

These findings raise questions about the effectiveness of critical pathways in a competitive environment, concludes Steven D. Pearson, M.D., M.Sc., of Harvard Medical School. Dr. Pearson and his colleagues compared postoperative lengths of stay for patients who underwent coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy (surgical removal of all or part of the colon), thoracic surgery, or hysterectomy before and after pathway implementation at a university hospital. They also assessed changes in lengths of hospital stay for three procedures at neighboring hospitals without pathway programs.

After pathway implementation at the university hospital, the length of stay decreased 21 percent for total knee replacement, 9 percent for CABG surgery, 7 percent for thoracic surgery, 5 percent for hysterectomy, and 3 percent for colectomy. However, similar decreases were seen in the neighboring hospitals that did not have critical pathways or other specific efficiency initiatives. Staff at these hospitals said that competitive pressures, often driven by local health plans, led each hospital to focus on reducing length of stay, and that each group developed informal efforts to encourage greater efficiency.

See "Critical pathways intervention to reduce length of hospital stay," by Dr. Pearson, Sharon F. Kleefield, Ph.D., Jane R. Soukop, M.S., and others, in the February 15, 2001 American Journal of Medicine 110, pp. 175-180.

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