Several factors inhibit use of clinical pathways for ACS in China

The implementation of clinical pathways for ACS management has had little effect on quality of care at hospitals in China, according to recent results.

Lack of support from hospital leadership, disparities between hospital capacities and available resources, and fears of patient litigation are key system-level issues affecting the successful implementation of clinical pathways, researchers wrote in a related study.

In a cluster randomized controlled trial, researchers collected data to assess a quality improvement program established at 75 urban hospitals in China between October 2007 and August 2010. All included hospitals typically admitted more than 100 patients with ACS annually. The researchers randomly assigned 70 eligible hospitals to one of two groups: the intervention group, which incorporated the American Heart Association/American College of Cardiology guideline-based clinical pathways from the start; and the control group, which undertook the AHA/ACC clinical pathways at a later point.

The following key performance indicators were selected as the study’s primary outcomes, due to their association with clinical outcomes and cost-effectiveness:

The proportion of patients with a final diagnosis consistent with biomarker indications;
The proportion of patients with STEMI admitted within 12 hours of symptom onset who; received primary PCI or thrombolysis
Door-to-needle time for patients with STEMI treated with thrombolysis;
Door-to-balloon time for primary PCI recipients with STEMI;
The proportion of high-risk patients who received coronary angiography;
The proportion of low-risk patients who received functional testing;
The proportion of discharged patients on combination therapy;
Length of hospital stay.

These indicators, along with in-hospital all-cause and cardiac-related mortality, major adverse CV events and incidences of major bleeding, were assessed at 12 months after clinical pathway implementation in the intervention group and compared with the baseline data from the control hospitals, using data collected from 50 consecutive patient cases at each hospital.

Although pathway implementation was linked to an 11% increase in the proportion of patients discharged on appropriate medical therapy (62.7% vs. 31.15%; P=.004 after adjustment for potential confounders), no other significant improvements were observed for any of the evaluated performance indicators (P>.069 for all) or clinical outcomes.

“The introduction of clinical pathways for the management of ACS in a broad range of hospitals in China had a limited effect on measures of quality of care,” the researchers concluded. “These findings need to be understood in the context of the health care environment and health systems that have a direct bearing on the likelihood of effectiveness.”

In an accompanying study, researchers sought to identify system-level barriers preventing the successful implementation of AHA/ACC guideline-based clinical pathways in Chinese hospitals. This study incorporated 40 in-depth interviews with health care providers at 10 hospitals with varying success with clinical pathway incorporation. All participants were involved with the implementation of the pathway at their respective facilities.

Analysis of these interviews identified several key, system-level obstacles to successful clinical pathway implementation: support from leadership for the implementation of quality improvement; variation in the capacity and resources of hospitals to meet the guideline specifications; fear of patient disputes and litigation; limited health care funding and high out-of-pocket expenses; and patient-related factors, such as compliance with post-discharge treatment regimens or limited understanding of coronary disease prevention.

According to the researchers, these findings emphasize the need to increase the ability of hospitals to successfully incorporate clinical pathways for ACS treatment.

“ACS clinical pathways are acknowledged widely as beneficial, yet multiple organizational and wider system factors often countered both the implantation of the clinical pathway and the achievement of the desired quality standards outlined by the pathway,” the researchers concluded. “Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of ACS and potentially other hospitalized conditions in China.”

For more information:

Du X. Circ Cardiovasc Qual Outcomes. 2014;7:217-226.

Ranasinghe I. Circ Cardiovasc Qual Outcomes. 2014;7:209-216.

Disclosure: Some of the researchers reported receiving support from Sanofi-Aventis for both studies.