Pilot Project Purpose
Clinical pathways are one method of integrating evidence into local health care settings and structures. The purpose of this ECRI Institute–Penn Medicine EPC project was to evaluate the feasibility of using the updated 2016 AHRQ EPC report on the Early Diagnosis, Prevention, and Treatment of Clostridium difficile in our standard clinical pathway and dissemination process to develop an evidence-based clinical pathway for the treatment of Clostridium difficile infection (CDI) in the acute care setting.
- The AHRQ EPC report provided value by presenting an overview of the most updated evidence for antibiotic treatment for our stakeholder group, which included clinical and non-clinical members. We found that the AHRQ EPC Report served as an evidence standard and was particularly valuable given that the existing guidelines were outdated. Discrepancies found between the more recent AHRQ EPC report and the dated guidelines prompted critical discussions regarding the comparative efficacy of available treatments.
- This AHRQ EPC report would have been more useful in our pathway development process if it included a summary of recommendations from recent guidelines. The lack of a guideline synthesis reduced our ability to use this source as the sole resource to develop a clinical pathway.
- Access to up to date AHRQ EPC reports can be a useful resource to inform pathway development in the context of outdated guidelines. We recommend that AHRQ prioritize updating reports that are of particular value to health systems and develop communication channels with societies and professional organizations to alert them to newly published EPC reports, especially when findings have changed from previous standards of care.
- Additional recommendations for the AHRQ EPC program include (1) facilitating the sharing of clinical pathways across health systems by providing a moderated platform to host evidence-based clinical pathways from health systems or other organizations and (2) developing a methodology or grading tool for assessing the trustworthiness of clinical pathways.
Background. Clinical pathways are one method of promoting the uptake of evidence into clinical practice. The ECRI Institute–Penn Medicine EPC incorporated the updated 2016 AHRQ EPC report on Early Diagnosis, Prevention, and Treatment of Clostridium difficile in the development of a clinical pathway for treatment of Clostridium difficile infection (CDI) in the acute care setting. This EPC report was selected as it complements other CDI initiatives currently being undertaken at the University of Pennsylvania Health System (UPHS). The objective of this pilot project was to assess the incremental value of including AHRQ EPC report findings in the pathway development process, as well as examine the value these reports may contribute to the process, and the time and resource requirements for this activity.
Methods. UPHS is a multicenter academic health care system in the Philadelphia region. We recruited a clinical owner and a representative multidisciplinary stakeholder panel to participate in the development of a clinical pathway, including experts from infectious diseases, infection control, antimicrobial stewardship, pharmacy, hospital medicine, and the UPHS CDI initiative, as well as clinical informatics. This process was facilitated by the PennPathways Program Manager and Director of the Penn Medicine Center for Evidence-based Practice (CEP). ECRI Institute was responsible for conducting a rapid evidence review.
CEP used their existing 10-step framework for developing and disseminating clinical pathways across a geographically distributed health system. Steps include:
- Identifying an engaged clinical owner;
- Recruiting representative stakeholders;
- Conducting a rapid review of existing guidelines and pathways;
- Developing a prototype pathway;
- Reviewing the rapid review and pathway prototype with stakeholders;
- Conducting additional rapid reviews as necessary;
- Updating the pathway using asynchronous feedback by stakeholders as necessary;
- Quality assurance and finalizing content and meta-data;
- Developing a messaging strategy and disseminating; and
- Monitoring utilization and updating.
Steps 4, 7, 9, and 10 are facilitated via a Web-based tool (Dorsata Inc., Washington, DC).
Results. We initiated our evidence review (step 3) with a review of the AHRQ EPC report on CDI infection. We noted that the report lacked a synthesis of existing guidelines and pathways—products that are critical to the standard pathway development process at Penn Medicine. To address this gap, our partners at ECRI Institute conducted a rapid review of recent guidelines and pathways (step 3). We reviewed these two evidence products with the stakeholder group (step 5) and found that the EPC report was beneficial in that it provided a common understanding of the evidence, which was especially useful for stakeholders less familiar with the current evidence. During the stakeholder review, we identified several differences between the EPC report and recommendations from existing guidelines, which prompted important internal discussions regarding evidence-based treatment. In this respect, the EPC report served as an evidence standard. The CDI treatment clinical pathway was approved by the clinical stakeholders and disseminated through our PennPathways site on April 16, 2018. As of August 31, 2018, the pathway has been viewed 325 times. Total direct project hours were 331. The two project activities with the highest number of direct hours were the rapid evidence review (272 hours) and pathway development (37 hours). The CDI clinical pathway was also deposited to the CDS Connect website to facilitate dissemination and development of computer readable content across other health systems and settings.
Discussion. This pilot suggests that AHRQ EPC reports can provide value in the process of developing clinical pathways, but that inclusion of guideline recommendation summaries and guideline quality assessments and pathways from professional organizations, governments and major academic medical centers, will be necessary to meet their full potential. Our findings also suggest that providers utilize clinical pathways when available.
Suggested citation: Flores E, Jue JJ, Giradi G, Schoelles K, Umscheid CA. Use of a Clinical Pathway to Facilitate the Translation and Utilization of AHRQ EPC Report Findings. Methods Research Report. (Prepared by the ECRI Institute–Penn Medicine Evidence-based Practice Center under Contract No. 290-2015-0005-I.) AHRQ Publication No. 19-EHC002-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCMETHENGAGECLINICAL.
Flores EJ, Jue JJ, Giradi G, Schoelles K, Mull NK, Umscheid CA. AHRQ EPC Series on Improving Translation of Evidence: Use of a Clinical Pathway for C. Difficile Treatment to Facilitate the Translation of Research Findings into Practice. Jt Comm J Qual Patient Saf. 2019;45(12):822-828.