The province of Manitoba has set a goal of reducing time from suspicion of cancer to treatment to a target of sixty days. To attain this goal, a baseline understanding of current time intervals is required. This study examined system, diagnostic and treatment delay in adult patients (> 17) diagnosed with Lymphomas from 2005 to 2010 using administrative data (Manitoba Cancer Registry, Manitoba Health billing data and Hospital Abstract data) and a chart review of a random subset of patients. A triangulated data approach was used to identify suspicion of lymphoma and milestones in the patient journey and to measure delays in diagnosis and treatment. Using an iterative consultative process, an algorithm was built to identify index events likely related to subsequent lymphoma diagnosis. Then, claims data was searched for a referring provider for each index event. The last visit with a referring provider, prior to the first index event, was selected as date of high suspicion. The study found that 14.8% of patients met the provincial target of less than sixty days from suspicion to treatment. Median time from high suspicion to treatment, referred to as system delay, was 128 days and the median time from diagnosis to treatment was 41 days. Time to diagnosis accounted for two thirds of system delay. In conclusion, this study demonstrated the merit of a triangulated approach. As well the clinical pathway developed and the target timelines for milestones have operational value and can be used to direct process improvements to shorten delays for future patients. / February 2017

Abstract Since Mar. 1995, the National Health Insurance begin in Taiwan, the payment of health insurance gradually increase each year. For controlling the increasing costs, case payment was the most important method. For each hospital, using clinical pathway to control costs of case payment was an effective tool. But, there were still less literatures to discuss the efficiency of clinical pathway in Taiwan. We used a retrospective study design, to examine the length of stay, total costs and quality including the complications, morbidity and readmissions for total knee replacement surgery. The data before clinical pathway was from June 2001 to May 2002, total 219 cases. After clinical pathway, the data was from Jan. 2003 to Dec. 2003, total 207 cases. The results showed decrease length of stay from 7.4 to 6.6 days (10.8%), decrease total cost from 125,324 NTS to 119,100 NTS (4.97%) and the quality of complications and readmissions did not increase. In conclusion, the clinical pathway can improve length of stay, total costs and quality. Key words: case payment, clinical pathway, total knee replacement

The rise of medical expenses is a common problem in the whole- wide world. All those countries implementing National Health Insurance have been anxiously looking for solutions, and clinical pathway has been found to be the most effective tool to control the growth of medical expense and maintain the quality of healthcare. This study focuses on the development and implementation of clinical pathway of breast cancer who underwent modified radical mastectomy, and investigate the impact of implementation of clinical pathway on the control of the length of stay, inpatient medical care expenditures, healthcare quality, and patient¡¦s medical satisfaction. The 90 patients of MRM before implementation ( July 1999 to Sep. 2000 ) and 80 patients after implementation ( Jan. 2001 to Feb. 2002 ) are taken as the targets of this study. The major findings of the study are listed as follows: 1. Clinical pathway can reasonably control the length of stay. 2. Clinical pathway can reduce inpatient medical care expenditures. 3. Clinical pathway can improve healthcare quality. 4. Clinical pathway can improve patient¡¦s medical satisfaction. 5. Clinical pathway can influence doctor¡¦s partial practice pattern. Finally this study concludes that clinical pathway is an instructive tool for hospital management. Based on the results and discussion from the study, we suggest the implementation of clinical pathway cones best in conjunction with the impact of case payment; besides, the quality of medical care should be assured under the controlled medical cost.

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Clinical pathways have been studied to promote best practices in nursing and enhance patient satisfaction. For 10 years a pediatric orthopedic surgical team at a Midwest hospital has not had a clinical pathway to treat or standardize care for adolescents following posterior spinal fusion surgery. Pain scores and patients' length of stay were collected using a retrospective chart review. This information was used to revise preoperative education materials and develop a visual poster. The purpose of this project was to identify and develop a way to educate the pediatric nursing staff on the use of the developed educational materials, poster, and clinical pathway prior to its implementation. David A. Kolb's learning cycle and the experiential learning model was used as the theoretical foundation of this study. The quality improvement project for the nurses will be developed using a flipped classroom approach as the learning environment. Videos, scenarios, and small group activities will be created and used in an interactive learning environment. The study will use a pretest-posttest design of retrospective chart review data with the independent variable being the education provided to the nurses. Social implications related to this project are to provide information on the plan of care following surgery to the adolescent and caregiver. This project will promote positive social change for adolescents and caregivers who will be engaged in the postoperative care to increase their satisfaction and decrease their anxiety.

The outpatient care of the heart failure (HF) patient is fragmented due to the lack of evidence-based practice guidelines use. The primary goal of this project was to improve the care of the HF patient in the outpatient arena through use of clinical pathways using the logic model as the project framework. The intervention was carried out over a 4-week period on a convenience, random sample of patients (n = 80) attending a cardiology practice. The patients were recruited from 2 physicians' patient populations and were selected based on an adult diagnosis of HF, reduced ejection fraction of <40% at some point in time, and the New York Heart Association (NYHA) functional class II-V. Comparisons were made in the documentation of care between patients on or off the pathway. The intervention included documentation of patient education, care follow-up, medications, NYHA functional class, and symptom exacerbation, documented in the electronic medical record. The quality of care data were evaluated based on 3 of the Joint Commission core measures for outpatient care of the HF patient. Additional data were collected regarding use of the clinical pathway based on provider and week of implementation. Data were analyzed via a Chi-square test of independence comparing pathway use by provider and use of pathway as study progressed. The comparative results show statistically significant differences in use of the pathway by provider and a statistically significant increase in use during the project . The quality of care results varied in statistical significance. The pathway utilization increased over time and provided a method for standardizing documentation of care for the HF patient in this outpatient clinic, a benefit for HF patients and providers in this cardiology practice and beyond.

Title: The path(way) to a clean colon: Improving the management of functional constipation Authors: Sarah Nichols, D.O. Pediatrics Resident, Nathan Justice, M.D. Pediatrics Hospital Medicine, Anjali Malkani, M.D. Pediatric Gastroenterology, David Wood, M.D., MPH General Pediatrics and Adolescent Medicine Purpose / Objectives: Hospitalization for the treatment of functional constipation is a leading cause among encounters that incur a financial loss at our institution. There are few resources that describe best practices or quality improvement efforts in the management of children who are hospitalized with functional constipation. A clinical pathway was implemented to promote interventions that improve hospital resource utilization for this group of children. Design / Methods: A clinical pathway was developed by a multidisciplinary team of stakeholders. The pathway emphasized interventions known to improve resource utilization and believed to facilitate a more effective and efficient cleanout. The inpatient arm of the pathway was implemented on a 24-bed medical/surgical unit; members of the medical and clinical staff of this unit received education with dissemination of the pathway. An electronic order set was implemented concurrently to facilitate practitioners’ application of pathway recommendations. Plan-Do-Study-Act (PDSA) cycles were used to monitor process measures and outcomes. Inpatient utilization was selected as the primary outcome for this effort’s first iteration; length of stay and frequency of readmissions were monitored as a secondary outcome and balancing measure, respectively. Results: Pathway utilization reached 65% within two periods of implementation. Adherence to selected process measures exceeded 80% within two periods. Inpatient utilization demonstrated initial improvement, increasing from 20% at baseline to 50% post-implementation; however, it subsequently fell below baseline performance after third-party payers revised admission criteria during period 6. Length of stay and frequency of readmissions remained unchanged post-intervention. Conclusion / Discussion: A clinical pathway for the treatment of functional constipation was quickly adopted by clinicians within two periods of implementation (spanning two months). The pathway was effective at promoting interventions that improved inpatient utilization; however, these improvements could not be sustained in the face of an unanticipated, external force. Future improvement cycles will be directed at reducing the length of stay to improve hospital resource utilization.

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The aim of the thesis is to investigate the feasibility of using text mining methods to reconstruct patient journeys from unstructured clinical narratives. A novel method to extract and represent patient journeys is proposed and evaluated in this thesis. A composition of methods were designed, developed and evaluated to this end; which included health-related concept extraction, temporal information extraction, and concept clustering and automated work-flow generation. A suite of methods to extract clinical information from healthcare narratives were proposed and evaluated in order to enable chronological ordering of clinical concepts. Specifically, we proposed and evaluated a data-driven method to identify key clinical events (i.e., medical problems, treatments, and tests) using a sequence labelling algorithm, CRF, with a combination of lexical and syntactic features, and a rule-based post-processing method including label correction, boundary adjustment and false positive filter. The method was evaluated as part of the 2012 i2b2 challengeand achieved a state-of-the-art performance with a strict and lenient micro F1-measure of 83.45% and 91.13% respectively. A method to extract temporal expressions using a hybrid knowledge- (dictionary and rules) and data-driven (CRF) has been proposed and evaluated. The method demonstrated the state-of-the-art performance at the 2012 i2b2 challenge: F1-measure of 90.48% and accuracy of 70.44% for identification and normalisation respectively. For temporal ordering of events we proposed and evaluated a knowledge-driven method, with a F1-measure of 62.96% (considering the reduced temporal graph) or 70.22% for extraction of temporal links. The method developed consisted of initial rule-based identification and classification components which utilised contextual lexico-syntactic cues for inter-sentence links, string similarity for co-reference links, and subsequently a temporal closure component to calculate transitive relations of the extracted links. In a case study of survivors of childhood central nervous system tumours (medulloblastoma), qualitative evaluation showed that we were able to capture specific trends part of patient journeys. An overall quantitative evaluation score (average precision and recall) of 94-100% for individual and 97% for aggregated patient journeys were also achieved. Hence, indicating that text mining methods can be used to identify, extract and temporally organise key clinical concepts that make up a patient’s journey. We also presented an analyses of healthcare narratives, specifically exploring the content of clinical and patient narratives by using methods developed to extract patient journeys. We found that health-related quality of life concepts are more common in patient narrative, while clinical concepts (e.g., medical problems, treatments, tests) are more prevalent in clinical narratives. In addition, while both aggregated sets of narratives contain all investigated concepts; clinical narratives contain, proportionally, more health-related quality of life concepts than clinical concepts found in patient narratives. These results demonstrate that automated concept extraction, in particular health-related quality of life, as part of standard clinical practice is feasible. The proposed method presented herein demonstrated that text mining methods can be efficiently used to identify, extract and temporally organise key clinical concepts that make up a patient’s journey in a healthcare system. Automated reconstruction of patient journeys can potentially be of value for clinical practitioners and researchers, to aid large scale analyses of implemented care pathways, and subsequently help monitor, compare, develop and adjust clinical guidelines both in the areas of chronic diseases where there is plenty of data and rare conditions where potentially there are no established guidelines.