title: Impact of care pathways for in-hospital management of COPD exacerbation: a systematic review.
abstract: BACKGROUND
  In-hospital management of COPD exacerbation is suboptimal, and outcomes are poor. Care pathways are a possible strategy for optimizing care processes and outcomes.
  
  
  OBJECTIVE
  The aim of the literature review was to explore characteristics of existing care pathways for in-hospital management of COPD exacerbations and to address their impact on performance of care processes, clinical outcomes, and team functioning.
  
  
  METHODS
  A literature search was conducted for articles published between 1990 and 2010 in the electronic databases of Medline, CINAHL, EMBASE, and Cochrane Library. Main inclusion criteria were (I) patients hospitalized for a COPD exacerbation; (II) implementation and evaluation of a care pathway; (III) report of original research, including experimental and quasi experimental designs, variance analysis, and interviews of professionals and patients about their perception on pathway effectiveness.
  
  
  RESULTS
  Four studies with a quasi experimental design were included. Three studies used a pre-post test design; the fourth study was a non randomized controlled trial comparing an experimental group where patients were treated according to a care pathway with a control group where usual care was provided. The four studied care pathways were multidisciplinary structured care plans, outlining time-specific clinical interventions and responsibilities by discipline. Statistic analyses were rarely performed, and the trials used very divergent indicators to evaluate the impact of the care pathways. The studies described positive effects on blood sampling, daily weight measurement, arterial blood gas measurement, referral to rehabilitation, feelings of anxiety, length of stay, readmission, and in-hospital mortality.
  
  
  CONCLUSIONS
  Research on COPD care pathways is very limited. The studies described few positive effects of the care pathways on diagnostic processes and on clinical outcomes. Though due to limited statistical analysis and weak design of the studies, the internal validity of results is limited. Therefore, based on these studies the impact of care pathways on COPD exacerbation is inconclusive. These findings indicate the need for properly designed research like a cluster randomized controlled trial to evaluate the impact of COPD care pathways on performance of care processes, clinical outcomes, and teamwork.
authors.affiliation: Respiratory Division, University Hospitals Leuven, Belgium. cathy.lodewijckx@med.kuleuven.be
authors.forename: C
authors.initials: C
authors.lastname: Lodewijckx
authors.forename: W
authors.initials: W
authors.lastname: Sermeus
authors.forename: M
authors.initials: M
authors.lastname: Panella
authors.forename: S
authors.initials: S
authors.lastname: Deneckere
authors.forename: F
authors.initials: F
authors.lastname: Leigheb
authors.forename: M
authors.initials: M
authors.lastname: Decramer
authors.forename: K
authors.initials: K
authors.lastname: Vanhaecht
mesh_terms: D006760:Hospitalization; D006801:Humans; D029424:Pulmonary Disease, Chronic Obstructive / Q000503:physiopathology / Q000628:therapy*