title: The role of clinical care pathways: an experience with distal pancreatectomy.
abstract: BACKGROUND
  Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.
  
  
  METHODS
  A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.
  
  
  RESULTS
  There were no differences in patient characteristics between SCP (n=50) and pre-SCP patients (n=100). Laparoscopic technique (62% versus 13%, P<0.001), splenectomy (52% versus 38%, P=0.117), and concomitant major organ resection (24% versus 13%, P=0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P=0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P=0.025) and had shorter HLOS (6 versus 7 d, P=0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (-33%, P=0.001), concomitant major organ resection (+38%, P<0.001), and feeding tube placement (+68%, P<0.001) were independent predictors of HLOS.
  
  
  CONCLUSIONS
  Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina. Electronic address: daniel.nussbaum@duke.edu.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Nussbaum
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Kara
authors.initials: K
authors.lastname: Penne
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: Department of Biostatistics and Bioinformatics, Duke University Durham, North Carolina.
authors.forename: Sandra S
authors.initials: SS
authors.lastname: Stinnett
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Alexander
authors.initials: A
authors.lastname: Perez
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Rebekah R
authors.initials: RR
authors.lastname: White
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Clary
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Tyler
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Duke University Durham, North Carolina.
authors.forename: Dan G
authors.initials: DG
authors.lastname: Blazer
mesh_terms: D000328:Adult; D000368:Aged; D019091:Critical Pathways; D005260:Female; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies
keywords: Clinical care pathway; Clinical pathway; Critical pathway; Distal pancreatectomy; Pancreas cancer; Recovery pathway