On the eve of Care Pathways 2011, the international conference on care pathways, it is very interesting to see that, over the years, care pathways (also known as critical pathways, integrated care pathways or clinical pathways) are used as tools to implement evidence into practice. At the same time, the level of evidence in favour of using care pathways to improve patient care is accumulating. However, there is an intriguing methodological issue in studying the effect of care pathways, arising from the nature of the concept.

The European Pathway Association (E-P-A) (http://www.E-P-A.org) defines a care pathway as: 'A complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period'. Characteristics of care pathways include: (i) an explicit statement of the goals and key elements of care based on evidence, best practice and patients' expectations and their characteristics; (ii) the facilitation of the communication among the team members and with patients and families; (iii) the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; (iv) the documentation, monitoring, and evaluation of variances and outcomes; and (v) the identification of the appropriate resources. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction and optimising the use of resources.1,2,3

A care pathway is not defined as a document or a tool but as a 'complex intervention'. The Medical Research Council states that complex interventions in healthcare, whether therapeutic or preventative, comprise a number of separate elements that seem essential to the proper functioning of the intervention, although the 'active component' of the intervention that is effective is difficult to specify.3,4 If a randomised controlled trial (RCT) of a drug versus a placebo is at the one end of the spectrum, a comparison of a stroke unit or nurse-led clinic with traditional care might be at the most complex other end of the spectrum. The greater the difficulty in defining precisely what the 'active components' of an intervention are, and how they relate to each other, the greater the likelihood that you are dealing with a complex intervention.2,4,5

This is also the case in the evidence synthesis in this volume of the journal by Schadewaldt and Schultz on nurse-led clinics for cardiac patients.6 The interventions that are being studied in the RCTs included in the systematic review they use are numerous and it is difficult to specify the 'active component'. It is very positive that two of the seven included RCTs had cluster designs. According to the Medical Research Council a cluster RCT is the preferred methodology for evaluating the effect of complex interventions.4,5,6,7

Care pathways are more similar to the complexity of nurse-led clinics than to the simplicity of giving a single drug. When developing and implementing a care pathway, part of the active ingredients of the complex intervention are the multidisciplinary teamwork, understanding the practical organisation of care and the integration of a set of evidence-based key interventions and outcomes. So let us be careful with being over-enthusiastic about conclusions made in literature reviews on complex interventions as nurse-led clinics or care pathways. It is very difficult to capture the concept that is being studied. It is a good thing that Schadewaldt and Schultz focused on one specific condition. Performing a systematic review on nurse-led clinics for different conditions will make the challenge even bigger. A thorough discussion on this will soon be published in Evaluation & the Health Professions.8

The conclusion of the work by McKenzie et al. on the value of a national office to coordinate the implementation of the Liverpool Care Pathway is well aligned to the concept of a complex intervention.9 Based on a two-phase survey among key stakeholders, it is concluded that a national office, in the context of the country's own healthcare system (ergo: understanding the practical organisation of care), is crucial for the sustained implementation of the Liverpool Care Pathway.

The two systematic reviews in this volume may help to generate another 'active component': evidence-based key interventions. Lim et al. report on a systematic review of anxiety in women with breast cancer, undergoing chemotherapy.10 Crouch and colleagues show that lifestyle interventions delivered by primary care providers in primary care settings to patients at low risk for heart disease might be of 'marginal benefit' and therefore should not be part of any care pathway!!11

The evidence base of specific healthcare interventions (including complex interventions) will continue to grow as already discussed in an editorial in this journal in 2010.12 With the use of complex interventions such as care pathways, nurse-led clinics, care bundles or stroke units, the improvement of healthcare delivery (effectiveness, feasibility, meaningfulness) could be an unstoppable process. But as not all complex interventions have proven theireffectiveness yet, we will need to keep on sharing knowledge in our search for optimal quality of care for all our patients.

References