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Are critical pathways effective for reducing postoperative length of stay?
Sydney Morss Dy1, Pushkal P Garg, Dorothy Nyberg
1Robert Wood Johnson Clinical Scholars Program, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. sdy@jhsph.edu
Background:
Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures.
Objective:
To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS.
Research Design:
Retrospective cohort study, from 1988 to 1998.
Setting:
Academic medical center department of surgery.
Subjects:
A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database.
Measure:
A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS.
Results:
Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS.
Conclusion:
Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.