A critical evaluation of critical pathways in head and neck cancer.
BACKGROUND
Critical pathways have been purported to decrease resource utilization in the management of head and neck cancer. Prior reports have documented shorter lengths of stay (LOS) for pathway patients than for historical cohorts.


OBJECTIVE
To critically evaluate the impact of critical pathways on LOS after laryngectomy.


METHODS
Length-of-stay trends of 2 concurrent observational cohorts of laryngectomy patients (September 1992 to February 1999) were compared, 1 at each of 2 medical centers. One center instituted a critical pathway for laryngectomy patients in February 1997; the other never used such pathways. In addition, we examined the independent impact of the critical pathway at the pathway institution after controlling for date of laryngectomy (which reflected temporal trends) and other confounding variables.


RESULTS
Both centers experienced reductions in LOS after February 1997, but there was no statistically significant difference between the reductions (1.9 days at the pathway center vs 1.5 days at the nonpathway center; P>.05). Multivariable linear and linear spline regression models demonstrated that the use of critical pathways at the pathway institution had no statistically significant impact on LOS after controlling for the date of laryngectomy.


CONCLUSIONS
Pathway implementation has a limited direct impact on LOS in relatively low-volume procedures such as laryngectomy. Although pathways may influence utilization trends, their impact is likely mediated by the development and educational process that accompanies pathway adoption rather than implementation of the pathway itself. The inclusion of temporal trends and contemporary cohorts provides substantial insight into the effectiveness of critical pathways.
Yueh
Bevan
B
Health Services Research and Development Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA. byueh@u.washington.edu
Weaver
Edward M
EM
Bradley
Elizabeth H
EH
Krumholz
Harlan M
HM
Heagerty
Patrick
P
Conley
Anna
A
Sasaki
Clarence T
CT
D000368:Aged; D003237:Connecticut; D019091:Critical Pathways; D005260:Female; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged