Abstract
This is the first issue of the International Journal of Care Pathways (IJCP) that has been edited by the European Pathway Association team. The European Pathway Association (ivzw) is an international not-for-profit association. The goal of our association is to perform international research, to organize international knowledge sharing, to support international collaboration and to advise policy-makers on care pathways. Therefore, in this issue, we have decided to focus on presenting different international experiences on care pathways inside and outside Europe.
The articles in this issue of the IJCP originate from a conference that took place on 28 May 2009 in Leuven, Belgium, held to mark 10 years of care pathways in Belgium. The conference was a landmark in showing that the developments in care pathways, although still quite recent, are growing fast.
Kathy Bower, principal and co-owner of the Center for Case Management in the USA, was one of the first keynote speakers, and talked about the very first beginnings of care pathways, 25 years ago, in the New England Medical Center (now Tufts Medical Center) in 1984. Their origin coincided with the onset of Diagnosis Related Groups (DRGs) in the USA as a method of cost-containment. DRGs were used to define homogeneous patient groups for which a prospective payment rate was set. It forced managers and clinicians to start organizing the care they were providing. In Belgium, research on care pathways began in 1996, mainly based on the experiences in the USA and in the meantime also in the UK. It was the basis for launching the Belgian–Dutch Clinical Pathway Network (
The Network was defined as a knowledge-sharing network between academia and health-care facilities. The aim of the Network was to improve the effectiveness of developing, implementing and evaluating care pathways. The Network started with eight corporate members (all hospitals). In 2009, the number of members increased to up to more than 100 health-care organizations, broadening the scope from hospitals to home care organizations, rehabilitation centres and mental health organizations. The number of care pathways that are in development or up and running in these organizations has grown to more than 1000 different projects. The top of this list is led by conditions with a high predictive flow of care such as total hip and knee arthroplasty and normal delivery. But the list of conditions for which care pathways have been built is long and varies from simple to complex procedures, and high to low predictability. About 9% of all care pathways are crossing the boundary of their own organization, mainly in bridging the continuum between primary and secondary care. The Network in 2000 was mainly focusing on Flemish acute hospital care. As there was interest from the Netherlands and French-speaking Belgian hospitals, the Network looked for collaboration with the Dutch Institute for Quality improvement and the Université Catholic de Louvain as care pathway facilitating centres, for The Netherlands and the French-speaking region of Belgium, respectively. In 2004 the European Pathway Association (
It was exactly this Belgian and international history line that the Leuven conference of May 2009 was planned to show, as there has been incredible development during these last 10 years in pathways.
At the same time, the actual care pathways do not look familiar anymore to their relatives from the early days. Although the first aim of care pathways was cost-containment, the actual focus is on quality and safety. Cost-efficiency has almost become the byproduct of well-organized care. The main purpose is to give the right care to meet the needs of patients. Although the care pathways of the early days were very focused in bringing a team together and enhancing communication and coordination, the new care pathways are focused on integrating guidelines and evidence-based care. The care pathway is seen more and more as a means to how guidelines can be put in practice by interdisciplinary teams. The care pathway approach realize that interdisciplinary teams, often varying from a few to more than 100 members, will have the same focus, where roles are discussed and set, communication channels are discussed and most importantly, where they adhere to the same evidence-based standards.
During the conference Thomas Rotter, research fellow and lead of the German–Australian Cochrane group, gave a first overview of the results of their work. Massimiliano Panella, professor in Public Health at the University of Piemonte Orientale ‘Amedeo Avogadro’ and president of the European Pathway Association, shows in his paper in this issue, the effect of working with a well-designed pathway, built based on state-of-the-art evidence on mortality and patient outcomes. The early care pathways were put on paper, which sometimes led to more administrative burden for health professionals. The new pathways of the future will be digital. They will require uniform digital platforms, communication and documentation standards, and integration of care pathways in patient records and clinical documentation systems, determining access rights. Ricard Rosique, head of the medical department of B-Braun in Spain, shows in his paper in this issue how these digital systems can be designed and work. The early pathways put a lot of their effort in organizing care by defining the team members' role, but it still depended highly on the individual professional if these arrangements were to be put in practice. These pathways were not embedded in systems. The new care pathways will code these organizational arrangements into the systems, such as scheduling and workflow systems. Professor Martin Elliot, a paediatric cardiac surgeon at London's Great Ormond Street Hospital, showed in his presentation at the Leuven conference how interdisciplinary teams in charge of a vulnerable patient will operate in the future. He learned these lessons from collaboration with the Formula 1 racing sector. The future will be in developing a care pathway and rehersing it as many times as necessary for it to become perfect, before implementing it. Early pathways focused on the simple, predictive, high volume processes. The change from acute to chronic care means more and more processes will be complex with a high level of uncertainty. This requires different strategies to deal with care pathways. John Ellershaw, Professor at Liverpool University and Director of the Marie Curie Palliative Care Institute, and his colleagues show in their paper in this issue how the methodology of care pathways can be used for a vulnerable patient group, such as palliative patients, in whom care should be personalized, and where needs are so individual. Again, care pathways have raised the quality of care during the last days of life and death. In the early days, care pathways were said to be patient-centred, but in fact they were streamlining the work of health professionals. The actual care pathways start and end with the patient and their relatives. They have an active role in developing care pathways and are seen as members of the care team. Indicators are patient-focused. Clare Gallagher, Healthcare Events London, focused on this changing role of patients in health care and care pathways at the Leuven conference. Early care pathways focused on the organization of care within organizations. Actual pathways follow the patient journey across health-care settings. Claire Whittle's presentation, as described in her paper in this issue, outlined the development of the Integrated Care Pathways Appraisal Tool (ICPAT), which identifies the essential components that should be contained in an ICP, as well as good practice regarding the development, implementation and maintanance of care pathways. Kris Vanhaecht, Research Fellow at the Centre for Health Services & Nursing Science at the Catholic University Leuven and secretary-general of the European Pathway Association, focuses in his paper, on the value of care pathways across the borders of health-care organizations, as one of the five pieces of the future pathway puzzle.
Ten years of care pathways in Europe have created high impact and expectations. We think that care pathways are at the heart of quality and patient safety. We also think that they are central in discussions about health-care organizations and sustainability of the health system. The IJCP has an important task in guiding and leading these discussions. We want to close this first editorial by thanking Jenny Gray for her great work as previous editor of the journal and welcoming readers to the new IJCP. We hope to go a long way together.