title: Does a clinical pathway improve the quality of care for sickle cell anemia?
abstract: BACKGROUND
  Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.
  
  
  RESULTS
  Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.
  
  
  CONCLUSIONS
  Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.
authors.affiliation: Massachusetts General Hospital, Center for Child and Adolescent Health Policy, Boston, USA. jco@partners.org
authors.forename: John Patrick T
authors.initials: JP
authors.lastname: Co
authors.forename: Kevin B
authors.initials: KB
authors.lastname: Johnson
authors.forename: Anne K
authors.initials: AK
authors.lastname: Duggan
authors.forename: James F
authors.initials: JF
authors.lastname: Casella
authors.forename: Modena
authors.initials: M
authors.lastname: Wilson
mesh_terms: D000293:Adolescent; D016058:Analgesia, Patient-Controlled; D000755:Anemia, Sickle Cell / Q000150:complications* / Q000503:physiopathology / Q000628:therapy*; D015142:Baltimore; D001945:Breathing Exercises; D002648:Child; D002675:Child, Preschool; D003251:Constriction, Pathologic / Q000209:etiology; D019091:Critical Pathways; D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007262:Infusions, Intravenous / Q000706:statistics & numerical data; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010146:Pain / Q000188:drug therapy / Q000209:etiology; D010147:Pain Measurement / Q000706:statistics & numerical data; D001261:Pulmonary Atelectasis / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D013147:Spirometry / Q000706:statistics & numerical data