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A Critical Evaluation of Critical Pathways in Head and Neck Cancer
Bevan Yueh, MD, MPH;
Edward M. Weaver, MD, MPH;
Elizabeth H. Bradley, PhD;
Harlan M. Krumholz, MD, MPH;
Patrick Heagerty, PhD;
Anna Conley, RN;
Clarence T. Sasaki, MD
Arch Otolaryngol Head Neck Surg. 2003;129:89-95.
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.
Design 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.
From the Health Services Research and Development Service (Drs Yueh and Heagerty) and Surgery and Perioperative Care Service (Drs Yueh and Weaver), Veterans Affairs Puget Sound Health Care System, Seattle, Wash; Departments of Otolaryngology–Head and Neck Surgery (Drs Yueh and Weaver), Health Services (Dr Yueh), and Biostatistics (Dr Heagerty) and Center for Cost and Outcomes Research (Drs Yueh, Weaver, and Heagerty), University of Washington, Seattle; and Departments of Epidemiology and Public Health, Division of Health Policy and Administration (Dr Bradley), Medicine Section of Cardiology (Dr Krumholz), and Surgery, Section of Otolaryngology (Dr Sasaki) and Center for Outcomes Research and Evaluation (Dr Krumholz and Ms Conley), Yale University, New Haven Conn.
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