The Effectiveness of Integrated Care Pathways for Adults and Children in Health Care Settings: A Systematic Review

Background Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient's journey and aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education. While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their 'active ingredients' is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are 'complex interventions' and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects. This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: 'Are ICPs effective?', our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley's realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions. Objectives To identify the purposes for which ICPs are effective, for whom and in what contexts; To identify the purposes for which ICPs are not effective, for whom and in what contexts; To produce recommendations on how ICPs should be used in the full range of health care settings. Inclusion Criteria Types of participants - The review focused on adults and children that accessed health care settings in which ICPs are used. Types of intervention(s)/phenomena of interest - For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA): An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations; Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives; The documentation, monitoring, and evaluation of variances and outcomes; The identification of the appropriate resources. Here multidisciplinary is taken to refer to the involvement of two or more disciplines. Types of outcomes - Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed. Types of studies - To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported between 1980 and 2008 (March) were included in the review. The search was restricted to publications after 1980 coinciding with the emergence of ICPs in the health care context. Non-English language studies were considered for inclusion based on the English language abstract where this was available. Papers were included if an English, German or French translation was available. Exclusion Criteria The review excluded studies that: Did not meet the definition of ICPs utilised for the purposes of the review; Evaluated ICPs as part of a wider service development and where the effects of the ICP were indistinguishable from the overall quality improvement programme; Where the ICP was not evaluated in real-life healthcare settings (i.e. where the ICP was implemented by research nurses who were additional to normal staffing levels). Search strategy The strategy consisted of high precision MeSH and non-MeSH index terms and keywords to ensure that all relevant material was captured (Appendix I). To avoid any potential replication, initial searches of the Joanna Briggs Institute for Evidence Based Nursing and Midwifery and Cochrane Library databases were conducted to establish that no other systematic reviews existed or were currently in progress. Following these initial enquiries a three step search strategy was designed to identify both published and unpublished studies. Stage one involved searching online databases using preliminary keywords, stage two involved using additional search words identified in the title or abstracts found in stage one and stage three involved hand searches of reference lists, bibliographies and key journals including the Journal of Integrated Care Pathways and International Journal of Integrated Care. Data collection Our search strategy located 4055 papers, of which 31 were retrieved for further evaluation. We critically appraised 9 papers, representing 7 studies. These studies were appraised for methodological quality using the JBI Critical Appraisal Checklist for Experimental Studies (See Appendix II). This appraisal focused specifically upon the reliability and validity of the study method and findings. Two reviewers independently assessed all of the included studies. In cases where reviewers could not reach an agreement a third reviewer was consulted. If disagreement was due to a lack of information then the study authors were contacted for clarification. Following the process of critical appraisal, 9 papers which represents 7 studies, were considered to be of a high enough quality to proceed to data extraction. Data Extraction As the aim of the review was to capture information on context as well as effectiveness, a bespoke data extraction tool was developed. The tool drew on the information included in the JBI extraction sheet for experimental studies and also incorporated specific information and issues relevant to the purpose of the review including aspects of ICP purpose, information on context and critical success factors (Appendix III). Data synthesis Given the heterogeneity of the included studies meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is therefore presented. Results When are ICPs effective, for whom and in what circumstances? Based on the evidence considered in this review, we conclude that: For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. ICPs can be effective in improving physician agreement about treatment options. ICPs can be effective in supporting decision-making when they incorporate a decision-aide. The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. When are ICPs not effective, for whom and in what circumstances? Based on the evidence considered in this review we conclude that: ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well-established. Depending on their purpose, the benefits of ICPs may be greater for certain patient sub-groups than others. We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. ICP documentation can introduce scope for new kinds of error. What are the active ingredients of ICPs and the generative mechanisms through which they have their effects? Active Ingredients - We have argued that ICPs are a classic example of a complex intervention. That is they comprise 'a number of separate elements which seem essential to the proper functioning of the intervention although the "active ingredient" of the intervention that is effective is difficult to specify'. None of the studies included in the review were underpinned by explicit theories of ICPs' active ingredients or their generative effects. Moreover, the information provided on ICP development and implementation processes was varied and in no case was any evidence provided to enable the role of these components of the intervention to be assessed. The interventions described by the studies in the review varied in terms of their key components (Appendix IV). Generative Mechanisms - Although none of the studies explicitly address the question of generative mechanisms, in several cases it was possible to make inferences about authors' implicit assumptions, based on the discussion sections of the papers (Appendix V). On the basis of the evidence considered in the review we suggest that ICPs can be considered as having a multiple role as directing, coordinating, organising, decision-making, and accumulating devices. In addition, because ICPs accumulate information, it seems reasonable to infer that they also function as 'distributing devices' by circulating information to users of the pathway, although no definitive evidence is provided in the studies reviewed to support this assertion. Conclusions Our review indicates that ICPs can have positive effects on service quality and efficiency as a result of their functions. They are effective in supporting the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. They also have value in supporting implementation of best practice guidelines and protocols by translating these into a format which is suitable for daily use by busy health professionals, thereby improving inter and intra-professional consensus and reducing unacceptable variations in clinical practice. Because they function as accumulating and distributing devices ICPs may also bring about improvements in documentation, which in turn augments their coordinating effects. They provide a focal point of reference - a common resource - to which various members can refer in order to understand where their role fits into the larger whole and determine what actions are necessary and when. Implications for practice Recommendation 1: Given the costs of their development, service providers should restrict ICP use to those areas of service provision where there are clearly identified deficiencies in existing care provision and/or where change is required. Recommendation 2: Prior to ICP development, developers should seek to specify how they wish to change practice, and which of the potential active ingredients of ICPs are necessary for this purpose. Recommendation 3: The evidence suggests that the ICP will change practice. It is imperative therefore, that the directions for action embedded in the tool are based on best practice or evidence. Recommendation 4: ICPs can be usefully deployed to make best practice guidelines available to staff in a form that is useable in daily practice. Recommendation 5: In cases where trajectories of care are more variable ICPs need to have greater degrees of in-built flexibility. Moreover, it is important that staff are supported in exercising professional judgement in those cases when adherence to the pathway is not in the individual patient's interest. Recommendation 6: ICP developers should consider carefully the patient population to whom the ICP applies and identify any sub-groups for whom its use may not be appropriate. Implications for research Recommendation 1: Primary research is necessary in order to provide stronger evidence of the active ingredients of ICPs, their generative mechanisms and inter-relationships. Recommendation 2: Evaluations of ICPs should specify the ingredients of the intervention, including processes to support development, implementation and sustainability as well as the detail of the ICP artefact itself. Recommendation 3: Evaluations of ICPs need to be underpinned by clarity as to the purposes of the intervention. Recommendation 4: Evaluations of ICPs must include theoretically informed outcome and process measures which take into account the perspective of all relevant stakeholders and the wider system effects of the intervention. Recommendation 5: Evaluations of ICPs should include theoretically informed process outcomes in order to develop understanding of ICP use in practice so that the reasons for behavioural change or its absence are understood. Recommendation 6: Evaluations of ICPs should provide adequate information on the 'control'. Recommendation 7: Evaluations of ICPs should provide adequate information on the local context, taking care to identify critical success factors. Recommendation 8: It is unlikely that ICPs will work for all purposes and in all contexts. Researchers should aim to produce realistic evaluations of ICPs which seek to develop an explanation (and therefore a theory) about how the intervention in question works in particular situations/contexts, by exploring the relationship between context, mechanism and outcome.