Integrated care pathways in neurosurgery: A systematic review.

IntroductionIntegrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success.MethodsElectronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded.ResultsTwenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods.ConclusionsICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient's perspective

Supporting integrated care pathways with workflow technology

Modern healthcare has moved to a focus on providing patient centric care rather than disease centred care. This new approach is provided by a unique care team which is formed to treat a patient. At the start of the treatment, the care team decide on the treatment pathway for the patient. This is a series of treatment stages where at the end of each stage, the care team use the patient’s current condition to decide whether the treatment moves to the next stage, continues in the treatment stage, or moves to an unanticipated stage. The initial treatment pathway for each patient is based on the clinical guidelines in an Integrated Care Pathway (ICP) [1] modified to suit the patient state. This research mapped a patient ICP decided by the healthcare providers into a Workflow Management System (WFMS) [2]. The clinical guidelines reflect the patient-centric flow to create an IT system supporting the care team. In the initial stage of the research the IT development team at Velindre Hospital identified that team communication and care coordination were obstacles hindering the implementation of a patient-centric delivery model. This was investigated to determine the causes, which were identified as difficulty in accessing the medical information held in dispersed legacy systems. Moreover, a major constraint in the domain is the need to keep legacy systems in operation and so there is a need to investigate approaches to enhance their functionalities. These information systems cannot be changed across all healthcare organisations and their complete autonomy needs to be retained as they are in constant use at the sites. Using workflow technology, an independent application representing an ICP was implemented. This was used to construct an independent layer in the software architecture to interact with legacy Clinical Information Systems (CISs) and so evolve their offered functionalities to support the teams. This was used to build a Virtual Organisation (VO) [3, 4] around a patient which facilitates patient-centric care. Moreover, the VO virtually integrates the data from legacy systems and ensures its availability (as needed) at the different treatment stages along the care pathway. Implications of the proposal include: formalising the treatment process, filtering and gathering the patient’s information, ensuring care continuity, and pro-acting to change. Evaluation of the proposal involved three stages; First, usefulness evaluation by the healthcare providers representing the users; Second, setup evaluation by developers of CISs; and Finally, technical evaluation by the community of the technology. The evaluation proved; the healthcare providers’ need for an adaptive and a proactive system, the possibility of adopting the proposed system, and the novelty and innovation of the proposed approach. The research proposes a patient-centric system achieved by creating a version of an ICP in the system for each patient. It also provides focussed support for team communication and care coordination, by identifying the treatment stages and providing the care team requirements at each stage. It utilises the data within the legacy system to be proactive. Moreover, it makes these required data for the actions available from the running legacy system which is required for patient-centred care. In the future the worth could be extended by mapping other ICPs into the system. This work has been published in four full papers. It found acceptance in the health informatics community [5, 6, 7] as well as the BPM community [8, 9]. It is also the winner of the 2011 “Global Award of Excellence in Adaptive Case Management (ACM)” in “Medical and Healthcare” [10] of the Workflow Management Coalition (WFMC) [11].EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Do integrated care pathways improve patient outcomes?

The purpose of the study was to determine if the use of an Integrated Care Pathway (ICP) was associated with more positive outcomes than traditional methods of care. The effectiveness of the ICP had not previously been tested (in relation to traditional methods of care) to determine if it made any difference, at a patient, staff or system (healthcare organisation) level. In February 2001 (as part of the NHS modernisation agenda) the gynaecology services within one UK city were re-organised and two separate units were merged into one new larger unit. Prior to the reorganisation, the two units offered similar treatments and were managed collectively; however, one site had developed and implemented ICPs and the other site had continued to use traditional methods of care delivery. ICPs are multidisciplinary plans for organising and delivering patient care. The plan of care is outlined in a sequential manner including all interventions with expected patient outcomes. The literature suggests that ICPs result in improved patient outcomes and lower hospital costs by decreasing length of stay and improving observations i.e. detecting signs of infection in a timelier manner. ICPs are recognised to facilitate the multidisciplinary partnerships in planning of patient care. However the literature was primarily anecdotal or non generalisable, and therefore additional local research was deemed essential. To ensure the research problem could be answered, three specific research questions were developed for testing: (1) What effect does an /~ / ICP have on the outcomes of gynaecological patients attending for major abdominal surgery? (2) What factors, including the use of an ICP contribute to the variance in length of stay for gynaecological patients? (3) What are the opinions of the staff who have used the ICP, of the ICP itself? Relevant directional hypothesis were derived from each research question. A quasi-experimental design was used to answer the first research question. Subjects were attached to one of two groups, a treatment group, which used the ICP, and a comparison group, which continued to deliver care based on traditional methods. Descriptive correlation was used to answer research question two and for the third research question descriptive exploration was used. Variables of interest from a patient, staff and system (health care organisational) level were collected to determine the effectiveness of the ICP compared with traditional methods. One of the difficulties faced with ICP research is the number of variables that can potentially influence patient care. Holzemer's model (1994, based on the work of Donabedian, 1966) was used to conceptualise the variables (and therefore the data collection instruments) into the category of structure, process or outcome at either a patient, provider or systems (health care organisation) level. This in turn helped to theorise the linkage between the variables within this study, identifying conceptual and functional relationships. The abdominal surgery ICP supported improvements in cost and efficiency through a reduction in length of stay (treatment site = 5.29 days, comparison site = 6.16 days) and a positive return to patients' perception of health. However, there was a reduction in patient satisfaction with nursing care with the introduction of the ICP and this needs further study. Involving patients in future developments and evaluations could promote long-term patient satisfaction

Supporting integrated care pathways with workflow technology

Modern healthcare has moved to a focus on providing patient centric care rather than disease centred care. This new approach is provided by a unique care team which is formed to treat a patient. At the start of the treatment, the care team decide on the treatment pathway for the patient. This is a series of treatment stages where at the end of each stage, the care team use the patient’s current condition to decide whether the treatment moves to the next stage, continues in the treatment stage, or moves to an unanticipated stage. The initial treatment pathway for each patient is based on the clinical guidelines in an Integrated Care Pathway (ICP) [1] modified to suit the patient state. This research mapped a patient ICP decided by the healthcare providers into a Workflow Management System (WFMS) [2]. The clinical guidelines reflect the patient-centric flow to create an IT system supporting the care team. In the initial stage of the research the IT development team at Velindre Hospital identified that team communication and care coordination were obstacles hindering the implementation of a patient-centric delivery model. This was investigated to determine the causes, which were identified as difficulty in accessing the medical information held in dispersed legacy systems. Moreover, a major constraint in the domain is the need to keep legacy systems in operation and so there is a need to investigate approaches to enhance their functionalities. These information systems cannot be changed across all healthcare organisations and their complete autonomy needs to be retained as they are in constant use at the sites. Using workflow technology, an independent application representing an ICP was implemented. This was used to construct an independent layer in the software architecture to interact with legacy Clinical Information Systems (CISs) and so evolve their offered functionalities to support the teams. This was used to build a Virtual Organisation (VO) [3, 4] around a patient which facilitates patient-centric care. Moreover, the VO virtually integrates the data from legacy systems and ensures its availability (as needed) at the different treatment stages along the care pathway. Implications of the proposal include: formalising the treatment process, filtering and gathering the patient’s information, ensuring care continuity, and pro-acting to change. Evaluation of the proposal involved three stages; First, usefulness evaluation by the healthcare providers representing the users; Second, setup evaluation by developers of CISs; and Finally, technical evaluation by the community of the technology. The evaluation proved; the healthcare providers’ need for an adaptive and a proactive system, the possibility of adopting the proposed system, and the novelty and innovation of the proposed approach. The research proposes a patient-centric system achieved by creating a version of an ICP in the system for each patient. It also provides focussed support for team communication and care coordination, by identifying the treatment stages and providing the care team requirements at each stage. It utilises the data within the legacy system to be proactive. Moreover, it makes these required data for the actions available from the running legacy system which is required for patient-centred care. In the future the worth could be extended by mapping other ICPs into the system. This work has been published in four full papers. It found acceptance in the health informatics community [5, 6, 7] as well as the BPM community [8, 9]. It is also the winner of the 2011 “Global Award of Excellence in Adaptive Case Management (ACM)” in “Medical and Healthcare” [10] of the Workflow Management Coalition (WFMC) [11].EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Supporting integrated care pathways with workflow technology

Modern healthcare has moved to a focus on providing patient centric care rather than disease centred care. This new approach is provided by a unique care team which is formed to treat a patient. At the start of the treatment, the care team decide on the treatment pathway for the patient. This is a series of treatment stages where at the end of each stage, the care team use the patient’s current condition to decide whether the treatment moves to the next stage, continues in the treatment stage, or moves to an unanticipated stage. The initial treatment pathway for each patient is based on the clinical guidelines in an Integrated Care Pathway (ICP) [1] modified to suit the patient state. This research mapped a patient ICP decided by the healthcare providers into a Workflow Management System (WFMS) [2]. The clinical guidelines reflect the patient-centric flow to create an IT system supporting the care team. In the initial stage of the research the IT development team at Velindre Hospital identified that team communication and care coordination were obstacles hindering the implementation of a patient-centric delivery model. This was investigated to determine the causes, which were identified as difficulty in accessing the medical information held in dispersed legacy systems. Moreover, a major constraint in the domain is the need to keep legacy systems in operation and so there is a need to investigate approaches to enhance their functionalities. These information systems cannot be changed across all healthcare organisations and their complete autonomy needs to be retained as they are in constant use at the sites. Using workflow technology, an independent application representing an ICP was implemented. This was used to construct an independent layer in the software architecture to interact with legacy Clinical Information Systems (CISs) and so evolve their offered functionalities to support the teams. This was used to build a Virtual Organisation (VO) [3, 4] around a patient which facilitates patient-centric care. Moreover, the VO virtually integrates the data from legacy systems and ensures its availability (as needed) at the different treatment stages along the care pathway. Implications of the proposal include: formalising the treatment process, filtering and gathering the patient’s information, ensuring care continuity, and pro-acting to change. Evaluation of the proposal involved three stages; First, usefulness evaluation by the healthcare providers representing the users; Second, setup evaluation by developers of CISs; and Finally, technical evaluation by the community of the technology. The evaluation proved; the healthcare providers’ need for an adaptive and a proactive system, the possibility of adopting the proposed system, and the novelty and innovation of the proposed approach. The research proposes a patient-centric system achieved by creating a version of an ICP in the system for each patient. It also provides focussed support for team communication and care coordination, by identifying the treatment stages and providing the care team requirements at each stage. It utilises the data within the legacy system to be proactive. Moreover, it makes these required data for the actions available from the running legacy system which is required for patient-centred care. In the future the worth could be extended by mapping other ICPs into the system. This work has been published in four full papers. It found acceptance in the health informatics community [5, 6, 7] as well as the BPM community [8, 9]. It is also the winner of the 2011 “Global Award of Excellence in Adaptive Case Management (ACM)” in “Medical and Healthcare” [10] of the Workflow Management Coalition (WFMC) [11]

ARIA 2016 Executive Summary Integrated care pathways for predictive medicine across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization (WHO) workshop in 1999. The initial goals were (i) to propose a new allergic rhinitis classification, (ii) to promote the concept of multi-morbidity in asthma and rhinitis and (iii) to develop guidelines with all stakeholders for global use in all countries and populations. ARIA - disseminated and implemented in over 70 countries globally - is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK (MACVIA (Contre les MAladies Chroniques pour un VIeillissement Actif)-ARIA Sentinel NetworK) uses mobile technology to develop care pathways in order to enable the management of rhinitis and asthma by a multi-disciplinary group or by patients themselves. An App (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom  control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.Keywords: ARIA, rhinitis, ICT, EIP on AHA, mobile technology, AIRWAYS ICP

A concept for integrated care pathways for atopic dermatitis-A GA2 LEN ADCARE initiative

INTRODUCTION: The integrated care pathways for atopic dermatitis (AD-ICPs) aim to bridge the gap between existing AD treatment evidence-based guidelines and expert opinion based on daily practice by offering a structured multidisciplinary plan for patient management of AD. ICPs have the potential to enhance guideline recommendations by combining interventions and aspects from different guidelines, integrating quality assurance, and describing co-ordination of care. Most importantly, patients can enter the ICPs at any level depending on AD severity, resources available in their country, and economic factors such as differences in insurance reimbursement systems. METHODS: The GA2 LEN ADCARE network and partners as well as all stakeholders, abbreviated as the AD-ICPs working group, were involved in the discussion and preparation of the AD ICPs during a series of subgroup workshops and meetings in years 2020 and 2021, after which the document was circulated within all GAL2 EN ADCARE centres. RESULTS: The AD-ICPs outline the diagnostic procedures, possible co-morbidities, different available treatment options including differential approaches for the pediatric population, and the role of the pharmacists and other stakeholders, as well as remaining unmet needs in the management of AD. CONCLUSION: The AD-ICPs provide a multidisciplinary plan for improved diagnosis, treatment, and patient feedback in AD management, as well as addressing critical unmet needs, including improved access to care, training specialists, implementation of educational programs, assessment on the impact of climate change, and fostering a personalised treatment approach. By focusing on these key areas, the initiative aims to pave the way for a brighter future in the management of AD

Adopting Integrated Care Pathways in Non–Small-Cell Lung Cancer: From Theory to Practice

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