Investigating Clinical Pathway Effects in Hospitals: Current Evidence and Proposal for a Realist Approach

Clinical pathways (CPWs) are tools used by healthcare professionals to guide evidence-based practice by improving multidisciplinary communication, teamwork, and care planning to optimize patient outcomes. CPWs are continually developed and implemented in several healthcare settings; however, the evidence of their effectiveness in hospitals is debatable to date. There is no coherent theory that explains how CPWs work in different healthcare settings. The overall objective of this thesis is to investigate the effects of CPWs implemented in hospitals. The first part (study 1) of this thesis described a statistical method to refine an operational definition for CPWs that is useful for conducting CPWs research in healthcare. The refined operational definition was used to synthesize evidence from CPW literature. The second part (study 2) of the thesis investigated the effects of CPWs in hospitals following the Cochrane systematic review methodology. The key finding in this review was that stand-alone CPWs may reduce in-hospital complications and hospital costs compared to usual care (low-certainty evidence) and it is uncertain whether stand-alone CPWs reduces the length of hospital stay or improve adherence to recommended practice by healthcare providers (very low-certainty evidence). The final section of the thesis (study 3) is a realist review protocol following the realist methodology to describe an evidence-based approach for developing a realist program theory with the aim of filling the theoretical void on how clinical pathways work in hospitals to generate intended outcomes. Taken together, these studies make a valuable addition to the growing body of research on clinical pathways implemented in hospitals. There is an urgent need to develop an internationally agreed definition for clinical pathways that can inform the development of plausible theories on how they work in hospital environments