Use and evaluation of critical pathways in hospitals.

CONTEXT: Although hospitals have devoted substantial resources to critical pathways, it is not known whether they routinely evaluate the clinical or economic effects of these pathways. OBJECTIVE: To determine how use and evaluation of critical pathways differ between academic and community hospitals. DESIGN: Cross-sectional survey. PARTICIPANTS: Hospitals participating in consortia for improving quality of care associated with the Institute of Health Care Improvement and the VHA, Inc. (formerly known as the Voluntary Hospitals of America, Inc.). Hospital administrators at 41 hospitals completed the survey (71% response rate), representing 13 academic medical centers, 13 community teaching hospitals, and 15 community hospitals. MEASURES: Use of critical pathways and measurement of clinical and economic outcomes of pathways. RESULTS: The median number of adult critical pathways used by academic hospitals, community teaching hospitals, and community hospitals was 25, 18, and 3, respectively. The most common pathways were community-acquired pneumonia, total hip or knee replacement, and stroke or transient ischemic attack. The percentage of hospitals with pathways dedicating staff to manage them was 78% for academic hospitals, 22% for community teaching hospitals, and 14% for community hospitals (P = 0.02). Evaluation practices varied widely among hospitals with pathways. Measures assessed included monitoring length of stay (85%), total hospital costs (74%), in-hospital mortality (62%), infectious complications (53%), readmission rates (47%), functional status (18%), and adverse drug events (15%). CONCLUSION: The use of critical pathways varies substantially among hospitals participating in quality improvement consortia. Use was highest in academic centers and lowest in community hospitals. Many hospitals with pathways do not track important clinical outcomes as part of their evaluation practices.