ACADEMIA AND CLINIC

Critical Pathways as a Strategy for Improving Care:

Problems and Potential
Steven D. Pearson, MD, MSc; Dorothy Goulart-Fisher, RN; and Thomas H. Lee, MD, MSc

• In an era of increasing competition in medical care, I n recent years, intense pressures to reduce the costs of
critical pathway guidelines have emerged as one of the health care have led many health care organizations to
most popular new initiatives intended to reduce costs seek strategies that reduce resource utilization while
while maintaining or even improving the quality of care. maintaining the quality of care (1-5). Among the most
Developed primarily for high-volume hospital diag- popular of the methods intended to meet this challenge
noses, critical pathways display goals for patients and are critical pathways. Critical pathways are management
provide the corresponding ideal sequence and timing plans that display goals for patients and provide the cor-
of staff actions for achieving those goals with optimal responding ideal sequence and timing of staff actions to
efficiency. achieve those goals with optimal efficiency (6-8). Interest
Despite the rapid dissemination of critical pathway in critical pathways has increased tremendously during the
programs in hospitals throughout the United States, past several years as early anecdotal reports of their cost-
many uncertainties remain about their development, saving potential have been disseminated, usually outside
implementation, and evaluation. In addition, serious the peer-reviewed medical literature (7, 9, 10).
concerns have been raised about their effect on patient The rapid push for critical pathway implementation
outcomes and satisfaction with care, physician auton- comes from intense competitive pressures and the persis-
omy, malpractice risks, and the teaching and research tent evidence of unexplained variation in medical practice
missions of many hospitals. Underlying these concerns (11, 12). Many managed care organizations have added
is the absence of data from controlled trials to evaluate their weight to this process by mandating certain critical
the effects of critical pathways. pathways or seeking partner hospitals that are willing to
Physicians should understand the potential benefits develop their own (7). However, no controlled study has
and problems associated with critical pathways be- shown a critical pathway to reduce the duration of hos-
cause physicians are increasingly being asked to pro- pital stay or to decrease resource use, nor has any study
vide leadership for pathway programs. Physicians and shown critical pathways to improve patient satisfaction or
other health service investigators should also develop outcomes (13). Nevertheless, like other promising medical
methods to study pathways in evolving health care technologies, critical pathways are being disseminated be-
settings. Although the promise of reduced costs and fore controlled trials have been done to evaluate their
improved quality is enticing, the gaps in our knowledge effectiveness.
about critical pathways are extensive; therefore, like Despite the lack of data, an increasing number of phy-
any new health care technology, pathway programs sicians will be asked to participate in critical pathway
should be fully evaluated in order to understand the development. Even more will find that their hospitalized
conditions under which that promise may be fulfilled. patients are already "on" pathways that they may or may
not have endorsed. To enhance the effectiveness of criti-
cal pathways—and minimize the disruption to the patient-
physician relationship—physicians and other caregivers
must understand the origin, potential benefits, and poten-
tial pitfalls of this new method.

Critical Pathways: A New Form of Clinical Guideline

Critical pathways have varying formats and are known
by many names, including critical paths, clinical pathways,
and care paths. Interpreted formally, a critical pathway is
the sequence of events in a process that takes the greatest
length of time. Like the techniques of continuous quality
improvement, critical pathway techniques were first devel-
oped for use in industry as a tool to identify and manage
the rate-limiting steps in production processes (14-17).
First developed in the 1950s, the Critical Path Method
was frequently linked with a similar approach, the Pro-
Ann Intern Med. 1995;123:941-948.
gram Evaluation and Review Technique, to coordinate
multiple contractors or persons in a project by identifying
From Brigham and Women's Hospital, Harvard Medical School,
Harvard Pilgrim Health Care, and Partners Community Health- the key sequence of events, or "critical path," the require-
Care, Inc., Boston, Massachusetts. For current author addresses, ments of which would drive the timeline of the overall
see end of text. project (18, 19). Critical pathway techniques have subse-

© 1995 American College of Physicians 941

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 Figure 1. The first 2 days of a sim-
plified critical pathway for patients
who have had cardiac surgery. This
general time-task matrix format,
also known as a Gantt chart, indi-
cates for each day of care the cor-
responding multidisciplinary staff
actions and expected patient out-
comes. CT = chest tube; CXR =
chest radiograph; EKG = electro-
cardiogram; ET = endotracheal tube;
ICU = intensive care unit; MD =
physician; PO = by mouth; POD1 =
first postoperative day;

quently been applied to projects as diverse as construc- patients and their families about the plan of care and
tion, civil engineering, town planning, marketing, ship involving them more fully in its implementation.
building, product design, and equipment installation (6). The general format of critical pathway guidelines is the
Critical pathways were first developed and applied to Gantt chart, which outlines the suggested patient care
health care in the 1980s, when prospective payment sys- process based on a time-task matrix, listing the compo-
tems focused greater interest on potential methods to nents of care in one column and cross-aligning these
improve hospital efficiency (6). Most of the first critical entries with columns pertaining to time (8). Figure 1 is an
pathways in hospitals were developed by nurses for nurs- example of such a chart for a critical pathway for patients
ing care alone (20, 21), but multidisciplinary teams soon who have had coronary artery bypass graft surgery. Cat-
began developing pathways to encompass all aspects of egories of multidisciplinary staff actions are listed in the
care for hospitalized patients (22-24). first column of the pathway, with specific actions for each
In general, efforts to develop critical pathways in health day of hospitalization. As indicated in Figure 1, a pa-
care have not incorporated the formal techniques used by tient's diet is expected to progress successfully from ice
industrial predecessors to identify the true "critical" path- chips to clear liquids on the first day after surgery. For all
way in any care process (18, 25). Instead, when critical other categories of patient care, critical pathways likewise
pathways are used to plan medical care, the specific goals explicitly mark the transition points of patient progress
usually include the following: and lay out a coordinated "map" of staff activities to
1. Selecting a "best practice" when practice styles vary achieve those transitions in the most efficient way possi-
unnecessarily. ble.
2. Defining standards for the expected duration of hos- Critical pathways differ from most clinical guidelines,
pital stay and for the use of tests and treatments. protocols, and algorithms in several key respects. First,
3. Examining the interrelations among the different clinical guidelines often address the appropriateness of
steps in the care process to find ways to coordinate or care by delineating the indications for tests or treatments.
decrease the time spent in the rate-limiting steps. Critical pathways, on the other hand, have almost always
4. Giving all hospital staff a common "game plan" from focused on the quality and efficiency of care after deci-
which to view and understand their various roles in the sions have already been made to admit the patient or
overall care process. perform the procedure. Another way in which critical
5. Providing a framework for collecting data on the pathways differ from most clinical guidelines is that they
care process so that providers can learn how often and are multidisciplinary in their development and in the
why patients do not follow an expected course during scope of their implementation. Critical pathways are also
their hospitalization. designed along specific timelines, sometimes even in hour-
6. Decreasing nursing and physician documentation by-hour detail, for indicated actions, and pathways not
burdens. only spell out these specific actions but also enumerate
7. Improving patient satisfaction with care by educating expected intermediate patient outcomes that serve as

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 checkpoints for the performance of both the patient and critical pathways that are developed without physician
the pathway. input have ended up sequestered in a part of the medical
Yet another distinguishing feature of critical pathways record where physicians do not often look (27, 30). Sim-
is that their comprehensive design allows them to be used ply gathering physicians, nurses, and other staff around
as a part of the patient record, often replacing other the same table, however, may not be enough to generate
documentation entirely (6, 24). All staff interventions and the level of teamwork and communication necessary for
intermediate clinical outcomes that occur as expected can success. It is an important challenge, especially for physi-
be simply initialed on the critical pathway document. If cians trained in an individualistic ethic, to learn how to
staff actions or intermediate patient outcomes do not participate in and lead these teams effectively (31, 32).
occur as expected, however, a "variance" from the path-
way is said to have occurred (26). Variances, too, can be
noted on the document, along with an explanation of The Pathway Development Process
their cause or causes, and, if needed, a plan can be The key steps in developing critical pathways vary from
described to return the patient to the expected course of institution to institution and from diagnosis to diagnosis.
treatment and outcomes. Nevertheless, two steps common to all pathway develop-
ment processes have been described (6, 8, 29).
Step 1. Evaluate the current process of care. The manner
Critical Pathway Development and extent to which critical pathway programs evaluate
Topic Selection the current care process vary widely (6, 9, 18, 25). All
authors urge that chart review be done to identify current
Critical pathways are typically developed for the hospi- variations in care and to understand the complex and
tal care associated with high-volume, high-cost diagnoses interdependent actions of all staff. Another goal of eval-
and procedures, particularly those for which inefficient uating the current care process is to identify specific out-
variation in the process of care is thought to exist (6). come criteria for discharge and for reaching intermediate
Surgical procedures, such as coronary artery bypass graft patient goals so that these criteria can be made key
surgery and total hip replacement, lend themselves par- elements of the pathway. However, to truly delineate the
ticularly well to critical pathways because the care process time-limiting path and key precedent relations among var-
differs relatively little from patient to patient. For this ious activities, some authors have also stressed moving
same reason, obstetric procedures such as normal vaginal beyond simple chart review and brainstorming to the use
delivery and cesarean section have also been subjects of of formal critical pathway techniques, including Critical
pathways in many institutions (24). Path Method and Program Evaluation and Review Tech-
For most medical diagnoses, however, patient care has nique, activity and precedent tables, flowcharts, and slack
proved more difficult to translate successfully into critical time determinations (18, 25). Although a full description
pathways because of the greater heterogeneity among pa- of these methods in pathway development is beyond the
tients and problems (6, 27). Some institutions have re- scope of this article, good descriptions can now be found
ported that pathways fail when used for medical patients in the medical literature (18, 25, 33).
who have either multiple problems and therefore multiple At our institution, we have found that critical pathway
relevant pathways or a problem that does not fit neatly teams benefit from a breakdown of the costs of hospital-
within any single standardized pathway (27-29). Despite ization. Team members are often surprised to learn the
these concerns, however, pathways have been designed relative importance of certain costs, such as pharmacy
and implemented at many institutions for medical diag- costs, in the overall cost of care for their patients. Know-
noses such as myocardial infarction, stroke, and deep ing the relative significance of different types of costs has
venous thrombosis (23). helped our teams ask new questions about the care pro-
cess, and the answers have helped them develop critical
Team Composition pathways with targeted innovations and changes to im-
prove efficiency.
The group that is organized to develop a critical path- Step 2. Evaluate medical evidence and external practices.
way should be multidisciplinary in order to bring to the In evaluating the current care process, critical pathway
table the knowledge and perspectives that are necessary teams discover variations and may find that the medical
to view the care process in its entirety. Although many literature can help inform clinical debates about the ef-
institutions have appointed nurses as the leaders of crit- fectiveness and appropriateness of tests and treatments.
ical pathway teams (6), we have found that having a We have let members of each critical pathway team de-
physician-expert lead each team lends credibility to the cide, in the course of their discussions, when and how to
pathways and builds a foundation of support among all evaluate the literature.
clinicians. Each pathway team should also have a group However, for many teams, the medical literature has
facilitator from the hospital administration, a housestaff been of limited importance in pathway development.
physician, a member of the quality management depart- Many of the questions of immediate importance to a
ment who has expertise in critical pathway methods, and pathway team, questions relating to the most effective
a community-based primary care physician, whose per- execution of care, have rarely been topics of well-con-
spective on inpatient care is likely to differ from that of trolled studies. For example, solid evidence on the effect
hospital-based physicians. of different durations of hospital stay on clinical outcomes
The lack of active involvement by physician-experts is or patient satisfaction is uncommon (34).
cited as a key reason for the failure of pathway programs; Given the dearth of evidence in the medical literature,

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 Figure 2. Documentation of ex-
pected actions and outcomes. A
simplified version of a page from a
critical pathway for patients who
have had coronary artery bypass
surgery. This page shows some of
the actions and intermediate out-
comes that are expected to occur
on the day of surgery. A level of
detail suitable for nursing documen-
tation is included, but, to encourage
physicians to participate, only the
two elements that are the most im-
portant to them are indicated in
bold print: 1) ordering an anesthe-
sia consult as part of an early extu-
bation protocol and 2) adequate
pain control with analgesics. D =
day nursing shift; E = evening nurs-
ing shift; N = night nursing shift;
VAR = variance.

anecdotal evidence, or "benchmarking," can be helpful to ficult for physicians to review, because they may list hun-
critical pathway teams (6). Many of our critical pathway dreds of specific tasks and patient outcomes.
teams have benefited from discussions on the care process Creating a format that will be used as part of the
with colleagues at other institutions or from examinations permanent medical record and that will be accepted and
of critical pathways already in use at other sites. We know used by physicians has been noted as the chief hurdle
of no collaborative efforts to develop critical pathways at faced by critical pathway programs (27, 29). One author
the regional or national level, but such efforts might offer has suggested that the time-task matrix common to most
the opportunity to build a broader-based consensus on critical pathway formats is too foreign to physicians and
controversial issues such as suggested durations of hospi- that pathways formatted as standardized order sets may
tal stay for various conditions. However, although it have the best chance at winning physician acceptance (27).
would be less costly to adopt critical pathways directly At our institution, we use a format that not only lists all
from consensus groups or other institutions, we share the patient actions for nursing documentation purposes but
impression of others that the active participation of local also identifies certain "key" elements in bold print that
physicians, nurses, and other staff in designing their own have been selected by the critical pathway team as most
pathway is essential to the success of these programs (29, relevant to the physician. An example of this format is
35). shown in Figure 2, a simplified version of a page from our
cardiac surgery pathway. In this format, both nurses and
physicians document on the same sheet. Physicians are
Critical Pathway Formats
encouraged to view the critical pathway as a whole, but if
Although the basic format of critical pathways is that of they prefer, they can focus rapidly on the key highlighted
the task-time matrix, the document itself can be format- steps in the patient care process. The critical pathway
ted in several different ways (8, 25). Some pathways are document is kept in the "physician" section of the med-
constructed as continuous, multipaged foldouts with space ical record, and physicians continue to write their own
left for pathway documentation alongside standard notes in sections of the critical pathway set aside for that
progress notes. Other pathways are formatted as single- purpose, while nurses document the achievement of all
paged educational tools, without space for direct docu- actions or expected outcomes by signing their initials in
mentation (23, 26). Some institutions are now experiment- the appropriate box for their shift ("D" for day, "E" for
ing with the computerization of pathways, linking them to evening, and "N" for night). If actions or outcomes do
laboratory test and pharmacy ordering systems, with the not occur as expected, nurses sign instead in the variance
goal of eliminating the paper chart entirely (28, 36). ("VAR") box, and in their written notes indicate an ac-
Having critical pathways serve as nursing documenta- tion plan for the variance.
tion tools often competes with the goal of involving phy- Although our strategies for balancing documentation
sicians in these programs, as is shown by the variety of needs and physician involvement continue to evolve, our
formats (27, 37). Some critical pathways try to account for experience with this format has been favorable. We have
nearly every action that would occur in the care process no formal measure of staff acceptance, but it is our sub-
so that nurses can simply check off boxes when these jective impression that this format has allowed our phy-
actions take place. However, the level of detail such doc- sicians and nurses to work comfortably together within
umentation necessitates makes daily critical pathways dif- the same critical pathway document.

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 Documenting and Analyzing Variances from the expected course has occurred, and the reason
for that variance and a plan to address it is then docu-
Another difficult challenge in pathway development is mented by the patient's nurse.
designing an effective method for documenting and ana- An example of this gateway variance method is shown
lyzing variance data (28). Variances are patient outcomes in Figure 3. The gateway identified here is the anticipated
or staff actions that do not meet the expectations of the transfer of a patient who has had cardiac surgery from an
critical pathway. Variances in staff actions are usually intensive care unit to an intermediate care ward within 24
considered omissions from what was suggested in the hours after surgery. If the patient reaches and passes
pathway, but they can also be "extra" actions that may through this gateway at the expected time, no variance
represent overutilization. Nevertheless, perhaps because data are generated, even if other specific actions of the
first-generation critical pathways usually focus on acceler- pathway are not completed. However, if the patient is not
ating the pace of staff actions, most systems of variance transferred from the intensive care unit within the ex-
analysis have evaluated only actions or outcomes that are pected time and needs to stay in the intensive care unit
expected but do not occur on time (26-28). for an additional day, then a gateway variance is recorded
Variance data provide the essential tool that places in a large box at the top of the critical pathway page for
critical pathways squarely within the tradition of continu- that day. Whenever a gateway variance is recorded, the
ous quality improvement. However, because every step in nurse also notes the reason or reasons the patient did not
a critical pathway can be considered a source of variance "pass through" the gateway on time. These data on gate-
if not completed or achieved within the time frame pro- way variance "causes," although subjective, can help one
posed by the pathway, many hospitals have found their evaluate current hypotheses and even gain new insights
data collection efforts overwhelmed with variances, most into the care process. By focusing on the frequency of
of which are not even important for evaluating clinical gateway failures and their underlying causes, the goal of
outcomes, patient satisfaction, or resource use (27-29). our variance system is to provide clinicians with insights
To overcome this difficulty, institutions have developed into critical steps in the care process without inundating
many different strategies to identify and measure vari- them with less relevant process data.
ances, and these strategies continue to evolve (28, 38-
41). Computer versions of critical pathways offer the ad-
vantage of being able to gather and analyze variance data Critical Pathway Implementation
without human intervention, although the interpretation
of large amounts of such data remains time-intensive (36). The early experience in the implementation of critical
At our institution, we are testing an approach in which pathways has been mixed. Enthusiastic qualitative reports
variances are defined and measured only at key transition have described benefits for patient empowerment and
points, or "gateways," within each pathway (18). Each physician-nurse interactions (9). Many case studies and
critical pathway team uses a combination of intuitive and uncontrolled comparisons have also cited reductions in
quantitative methods to select several key points at which duration of hospital stays of 5% to 40%; cost reductions
a patient outcome that does not occur as expected indi- of as much as 33%; significant improvements in readmis-
cates a significant risk for not meeting future time goals sion rates, wound infections, and other clinical outcomes;
and ultimately for not meeting the goal for duration of and significant increases in the rate of compliance with
hospitalization. Failure to "pass through" a gateway at the generally accepted standards of care (10, 21-23, 42).
expected time serves as a signal that a significant variance However, other reports have not been as favorable. A

Figure 3. Variance documentation.

This figure shows a simplified ver-
sion of the page of a critical path-
way for patients who had had cor-
onary artery bypass surgery that is
used if a patient does not achieve
the "gateway" of expected transfer
from the intensive care unit to an
intermediate care bed within 24
hours after surgery. Reasons for the
variance are documented by the
nurse who is caring for the patient
at the beginning of the patient's
second day in the intensive care
unit, and these data are used in on-
going evaluations of the pathway
and the care process. D = day nurs-
ing shift; E = evening nursing shift;
ECG = electrocardiogram; N =
night nursing shift; VAR = vari-

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 well-controlled study of a critical pathway for patients trol over patient care rather than as blunt instruments to
with stroke showed no significant effect on costs or clin- constrain clinical judgment in an effort to control costs.
ical outcomes (13). Also, according to some recent anec- Finding the proper balance between autonomy and
dotal reports, many critical pathway programs have met standardization may prove to be elusive. An open search
with physician resistance, and, in several cases, hundreds for this balance, however, involving a continuing dialogue
of pathways created by flourishing programs fell quickly among clinicians and the institution, should lie at the
into disuse and even disregard, despite their early success heart of any successful critical pathways program.
(27-29).
From both the successes and the failures, several Malpractice Risk
themes emerge regarding pathway implementation. Strong
support from hospital leaders is important to communi- Another frequently voiced concern is that physicians
cate the commitment of the institution to the pathways. may be more vulnerable to malpractice suits if they do
Piloting each critical pathway in a subset of patients helps not comply with a critical pathway and a patient has a
identify areas in which the pathway may need to be complication. Practice guidelines have been used more
changed and builds trust among hospital staff (27). often to implicate than to exonerate defendant physicians,
Before pathway programs are implemented, education and institutions may incur greater liability when they au-
of all hospital staff who will be involved is vital (29). thorize the use of a critical pathway (46, 47). However,
Nurses, physicians, and other care providers who have not the use of critical pathways cuts both ways: Attorneys
been directly involved in the development of the pathway surveyed in one study reported that the existence of
should understand and accept the goals of the pathway guidelines in certain cases had induced them not to bring
and the justification for the suggested duration of the suit in the first place (48), and other attorneys have
hospital stay and care process as a whole. This educa- described several ways in which critical pathways can de-
tional effort should include discussion of the methods for crease overall malpractice risk (47). Many malpractice
collection and analysis of data on variance from the crit- suits reach trial because of disagreement over what the
ical pathway. Clinicians may be concerned that they will standard of care should have been for the patient. Such
be punished in some way if they do not manage their disagreement is less likely to occur with critical pathways.
patients such that they meet all patient outcome and By establishing a management protocol that has been
action goals proposed by the pathway. Because fear tends reviewed by local opinion leaders, a critical pathway iden-
to accompany any significant change, these concerns tifies the appropriate standard of care and helps keep the
should be discussed openly. caregivers' attention focused on the most vital steps. Fur-
A central part of pathway implementation is the defi- thermore, because documentation is such an important
nition of roles and responsibilities on a day-to-day basis. aspect of pathways, if the physicians' management devi-
Will physicians document on the pathway? Will nurses ates from that suggested by the pathway, the reason be-
and physicians indicate variances from the pathway, and hind the deviation is also carefully documented.
who will have the responsibility for creating the plans to
address the variances? Should a case manager manage Research and Education
variance data collection? Will case managers have a clin-
ical role in managing patients' progress on the pathway? The research and educational missions of teaching hos-
Although the answers to these questions have varied pitals are already in jeopardy, and critical pathways may
among successful pathway programs, most authors urge seem to further undermine training by discouraging ex-
that physicians be as involved as possible, and all authors perimentation and independent thinking by trainees.
of reports on critical pathways have noted the importance Those responsible for housestaff education may feel that
of clearly defining staff roles before the pathways are critical pathways set forth given processes of care that
implemented (23, 27-29). stifle the questioning through which residents learn.
On the other hand, medical training may be well served
by incorporating methods such as critical pathways to
Concerns about Critical Pathways teach students about cost-effective practice. At our insti-
tution, we have incorporated critical pathways into our
Autonomy versus Standardization teaching programs by involving housestaff in all phases of
pathway development and implementation. We have also
A common response of physicians to critical pathways used the pathways themselves as teaching instruments in
is to view them as another manifestation of "cookbook lectures that explore the clinical controversies of path-
medicine" (43-45). However, although critical pathways ways. These activities have helped many members of the
encourage standardization as a strategy to improve quality housestaff overcome the natural resistance they have for
and efficiency, physicians may gain even greater control clinical "protocols" and have smoothed the integration of
over the care of their patients by helping define these pathways into our teaching hospital.
standards. Physicians who do clinical research may be concerned
Most institutions rely on the physician to judge when that strong institutional support will create an atmosphere
the individual needs of a patient require a different in which patients will be steered away from clinical re-
course of action. At any time, physicians at our institution search studies into treatment according to critical path-
can and do write orders that change the pathway for a ways. Critical pathways, however, are not meant to sup-
patient or remove a patient from a pathway completely. plant clinical research but rather to improve the "usual
Critical pathways are thus used as tools to increase con- care" that is delivered. For example, one critical pathway

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 at our institution includes explicit instructions to consider process and on reducing unnecessary variation, and their
patients for a clinical research protocol and to contact the attention to patient outcomes—all in a package that also
research team when appropriate. We have also encour- offers a tangible way to reduce the duration of hospital
aged the pathway development teams to think of research stays and resource use. However, despite the appealing
questions that may be embedded within their pathways, logic of this approach to quality improvement, serious
the answers for which may be discovered during the im- concerns and questions remain about the development,
plementation of the pathway—for example, during vari- implementation, and costs of critical pathways, as well as
ance analysis. about their true potential to reduce costs or improve
quality.
Effectiveness of Critical Pathways Methods to develop critical pathways remain unstudied
and are still evolving, with wide variations seen among
Despite the rapid implementation of critical pathway institutions in their approach to topic selection, team
programs, uncertainty persists about their effectiveness. composition, documentation of current care processes,
As mentioned previously, the only published controlled and the evaluation of the medical literature and other
study on a critical pathway found that pathways have no external benchmarks. Differences in the pathway develop-
effect on the duration of the hospital stay or on patient ment process underscore the striking differences reported
outcomes (13). In addition, we are aware of no studies among critical pathway formats and the strategies to im-
that have attempted to measure the costs of pathway plement pathways and gather variance data. Considerable
development, implementation, and maintenance. It has research is needed to explore which methods of pathway
also been suggested that the improvements that some development and implementation are most likely to pro-
authors have attributed to critical pathways could have vide benefits. Measuring the costs of critical pathways and
been achieved just as easily by simply instructing clinicians their impact on outpatient resources is essential to help-
to manage their patients within a specified target duration ing physicians and health care organizations determine
of stay (27). whether such programs are truly worth the effort. As the
However, many hospitals have concluded that the com- technology of critical pathways and their setting evolve, an
petitive environment will not allow them to wait for the important challenge for investigators will be to develop
results of rigorous trials before pursuing critical pathways. methods to evaluate pathway techniques and their impact.
Furthermore, performing controlled trials may prove to While future research is pursued, critical pathway pro-
be difficult because of "contamination" of any control grams are in place today, affecting the care of thousands
group with knowledge of the intervention. Studies in of patients daily. An important current challenge for phy-
which patients or physicians are randomly assigned to sicians is to participate in pathway development and im-
either a pathway or conventional management are there- plementation so that the management protocols reflect
fore not likely to be undertaken. their beliefs about care. Although critical pathways clearly
To measure the effectiveness of pathways in reducing hold the promise of reduced costs and improved quality,
costs, one must also measure costs for the entire episode the fulfillment of this promise requires the full and in-
of care, including not only the hospital phase but also any formed participation of physicians.
prehospital or posthospital care associated with the con-
Grant Support: Dr. Lee is an Established Investigator (900119) of the
dition. Critical pathways that reduce hospital costs by American Heart Association.
merely shifting equal or more costs into the outpatient
setting do not meet the true needs of patients or the Requests for Reprints: Thomas H. Lee, MD, Partners Community Health-
care, Inc., Prudential Tower, Suite 1150, 800 Boylston Street, Boston, MA
health care system. 02199-8001.
Even if valid data on resource use, patient satisfaction,
Current Author Addresses: Dr. Pearson: Department of Ambulatory Care
and outcomes can be gathered, the effectiveness of critical and Prevention, Harvard Pilgrim Health Care, 126 Brookline Avenue,
pathways at an institution may remain a value judgment. Boston, MA 02215.
What would happen, for instance, if a hospital imple- Ms. Goulart-Fisher: Brigham and Women's Hospital, 75 Francis Street,
Boston, MA 02115.
mented a pathway for acute chest pain and found out that Dr. Lee: Partners Community Healthcare, Inc., Prudential Tower, Suite
duration of the hospital stay and overall costs were re- 1150, 800 Boylston Street, Boston, MA 02199-8001.
duced, but that patients were now more likely to return to
the emergency department with recurrent pain, or were References
less satisfied with their care? Would the hospital change 1. Jones DA. Proprietary hospitals in cost containment. Am J Cardiol.
its pathway, and if so, how? Unfortunately, the cost, qual- 1985;56:40C-2C.
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