Use of critical pathways to improve efficiency: a cautionary tale.

BACKGROUND: Critical pathways are healthcare management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80% of hospitals in the United States use critical pathways for at least some of their patients. Unfortunately, critical pathway effectiveness in improving clinical efficiency is unclear. OBJECTIVES: To assess whether critical pathways have been successful in reducing patient length of stay (LOS) and resource utilization in our tertiary-care academic medical center. STUDY DESIGN: A before-and-after observational study using multivariate linear regression analyses. METHODS: We identified all critical pathways initiated in our medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation; 13 pathways satisfied these inclusion criteria. Using a before-and-after design, multivariate linear regression was used to evaluate each pathway's effect on average monthly LOS and resource utilization after adjusting for case mix and secular trends. RESULTS: Three of the 13 pathways were associated with a statistically significant immediate decrease in inpatient LOS: acute myocardial infarction (20.7% decrease; P = .001), cesarean section (14.6% decrease; P = .03), and kidney transplantation (24.5% decrease; P = .003). Only 1 pathway, percutaneous transluminal coronary angioplasty (PTCA), produced a statistically significant decrease in LOS slope (a decrease of 5.2% per month; P = .001). Two pathways were accompanied by a statistically significant immediate reduction in ancillary resource utilization: kidney transplantation (26.4% decrease; P = .001) and community-acquired pneumonia (21.8% decrease; P = .002). Only the PTCA pathway produced a statistically significant decrease in resource utilization slope during the 12-month follow-up period (a decrease of 8.4% per month; P < .001). CONCLUSIONS: Although some pathways did reduce LOS or resource utilization or both, most pathways reduced neither. Because substantial resources must be expended on pathway development, implementation, and maintenance, future efforts should be placed on further evaluating the effectiveness of critical pathways and understanding the reasons behind their success or failure before additional resources are consumed for this management strategy.

Effects of buspirone in withdrawal from opiates.

The purpose of this study is to evaluate the effectiveness of buspirone in attenuating withdrawal symptoms in heroin addicts and methadone-maintained patients following cessation of heroin or methadone use. Subjects were twenty hospitalized male chronic opiate users aged 30-55 who did not present any DSM-IV Axis I disorder with the exception of opioid dependence. For the first five days, patients received doses of methadone that were decreased to 30 mg and were maintained on this dose for the following three days. Methadone was then discontinued, and patients were randomly assigned to buspirone or placebo treatment from day nine to seventeen. The buspirone dose was 15 mg on day nine and 30 mg from day ten to day seventeen. Treatment was double-blind. Withdrawal symptoms were measured with the Objective Opiate Withdrawal Scale (OOWS) and the Subjective Opiate Withdrawal Scale (SOWS). Buspirone-treated patients had significantly lower scores on the OOWS on days thirteen (p=.040), fourteen (p=.025), fifteen (p=.035), and seventeen (p=.035). They also had lower scores on the SOWS on days sixteen (p=.050). It is concluded that buspirone was effective in attenuating the objective and subjective withdrawal symptoms that follow opiate use cessation.