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HealthJuly 30, 2021

Championing clinical pathways for high-value, individualized care

By: Anne C. Travis, MD, MSc, FACG, AGAF
Does my patient need an oral anticoagulant? Are they at risk for stroke? Which medication and dose are indicated? Every day, clinicians face decisions that significantly impact their patients. Advanced clinical pathways can help guide their decision-making to deliver optimal individualized patient care.

All clinicians want to do the right thing for their patients, but knowing what that is can be difficult, especially as the amount of medical information continues to grow and guidelines change. A gastroenterologist by training, I practiced at a large Boston hospital with access to a wide array of specialists who could assist me when I had questions about how to best treat a patient. However, not all clinicians have access to the expertise and support of a major academic medical center as I did.

In speaking with medical leaders in the U.S., they expressed a need for reliable clinical decision support to help manage common chronic conditions, such as heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. We realized we could leverage our expertise and core knowledge to help solve a problem every healthcare organization struggles with — unwarranted variability in care.

Using clinical pathways to increase adherence to quality measures, reduce unwarranted variability

Quality measures are developed based on guidelines and the medical literature and aim to promote the practice of evidence-based medicine. Pathways help support quality measure adherence by providing clinical decision support that encourages clinicians to practice to evidence-based medicine.

For example, the Centers for Medicare and Medicaid Services (CMS) quality measure for atrial fibrillation looks at what percentage of adults with atrial fibrillation are anticoagulated to decrease their stroke risk. Rates of anticoagulation are lower than they should be. Using a pathway can help clinicians determine if a patient is likely to benefit from an anticoagulant. Beyond that, the pathway can also help identify which anticoagulant is the best choice for the patient.

By following the recommendations in the pathway, clinicians will not only be practicing evidence-based medicine, they may also improve their quality measure performance and reduce unwarranted variability.

Noticeable trend: Increased variability with common complex conditions

Another challenge in reducing unwarranted variability in care is that, over time, patients have become more complex, with numerous chronic conditions. For example, the increasing prevalence of obesity has led to more patients with diabetes, hypertension, heart disease, and liver disease. Providing the best care requires that all these complex medical conditions be considered simultaneously. Failing to do so may contribute to a clinician not providing the patient with optimal care.

Pathways help clinicians identify patient characteristics and comorbid conditions that are important when making a diagnostic or management decision. For example, a patient with type 2 diabetes is typically prescribed an oral medication as the first line of treatment. There are numerous choices available, and comorbid illnesses such as heart disease, heart failure, and chronic kidney disease all influence the choice of medication. In addition to comorbid conditions, the clinician also needs to consider whether the patient needs to avoid medications that increase the risk of low blood sugar or if selecting a medication that is associated with weight loss is important.

If a clinician doesn’t take all these factors into account, the patient may not be started on the most appropriate medication. This could result in the patient having suboptimal blood glucose control, experiencing an adverse reaction, or missing the opportunity to take a medication that has additional benefits for the patient, such as decreasing the risk of being hospitalized with heart failure.

Clinicians weigh in on the benefits of pathways

The feedback we’ve received from clinicians is that clinical pathways get them to the answers they need, give them confidence in their decisions, and help them manage conditions they may not see frequently. This is especially important for conditions like chronic obstructive pulmonary disease (COPD) and heart failure, where correct management can help keep patients out of the hospital.

This feedback is very encouraging. As more clinicians use pathways, we expect to see improved patient outcomes and increased adherence to quality measures.

84% of users modified clinical decisions using the evidence-based information in UpToDate Pathways. Learn more about solutions from UpToDate Advanced.

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Anne C. Travis, MD, MSc, FACG, AGAF
Senior Director of Advanced Clinical Decision Support - Editorial, UpToDate®, Wolters Kluwer
Anne C. Travis, MD, MSc, FACG, AGAF is the Senior Director of Advanced Clinical Decision Support - Editorial for UpToDate® at Wolters Kluwer and leads the content creation for UpToDate Pathways.