Rotter T, Kinsman LD, Alsius A, Scott SD, Lawal A, Ronellenfitsch U, Plishka C, Groot G, Woods P, Coulson C, Bakel LA, Sears K, Ross-White A, Machotta A, Schultz TJ, et al.
The Cochrane database of systematic reviews. Date of publication 2025 May 14;volume 5(5):CD006632.
1. Cochrane Database Syst Rev. 2025 May 14;5(5):CD006632. doi:
10.1002/14651858.CD006632.pub3.
Clinical pathways for secondary care and the effects on professional practice,
patient outcomes, length of stay and hospital costs.
Rotter T(1), Kinsman LD(2), Alsius A(3), Scott SD(4), Lawal A(5), Ronellenfitsch
U(6), Plishka C(5), Groot G(7), Woods P(8), Coulson C(3), Bakel LA(9), Sears
K(10), Ross-White A(11)(12), Machotta A(13), Schultz TJ(14).
Author information:
(1)Healthcare Quality Programs, School of Nursing, Queen's University, Kingston,
Ontario, Canada.
(2)Violet Vines Marshman Centre for Rural Health Research, La Trobe University
Rural Health School, Bendigo, Australia.
(3)School of Nursing, Queen's University, Kingston, Canada.
(4)Faculty of Nursing, University of Alberta, Edmonton, Canada.
(5)College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon,
Canada.
(6)Department of Visceral, Vascular and Endocrine Surgery, Medical Faculty of
the Martin Luther University Halle-Wittenberg and University Hospital Halle
(Saale), Halle (Saale), Germany.
(7)College of Medicine, University of Saskatchewan, Saskatoon, Canada.
(8)College of Nursing, University of Saskatchewan, Saskatoon, Canada.
(9)Department of Pediatrics, University of Colorado School of Medicine and
Children's Hospital Colorado, Aurora, Colorado, USA.
(10)Queen's Collaboration for Health Care Quality: a JBI Centre of Excellence,
School of Nursing, Queen's University, Kingston, Ontario, Canada.
(11)Bracken Health Sciences Library, Queen's University, Kingston, Canada.
(12)Queen's Collaboration for Health Care Quality: a JBI Centre of Excellence,
Queen's University, Kingston, Canada.
(13)Department of Anesthesiology, Sophia Children's Hospital, Erasmus Medical
Centre, Rotterdam, Netherlands.
(14)Flinders Health and Medical Research Institute, Flinders University, Bedford
Park, Australia.
Update of
Cochrane Database Syst Rev. 2010 Mar 17;(3):CD006632. doi:
10.1002/14651858.CD006632.pub2.
BACKGROUND: Clinical pathways (CPWs) are structured multidisciplinary care
plans. They aim to translate evidence into practice and optimize clinical
outcomes. This is the first update of the previous systematic review.
OBJECTIVES: To investigate the effect of CPWs on patient outcomes, length of
stay, costs and charges, adherence to recommended practice, and to measure the
impact of different approaches to implementation of CPWs.
SEARCH METHODS: For this update, CENTRAL, MEDLINE, and Embase were searched on
25 July 2024. Two trial registries were searched on 26 July 2024, along with
reference checking, citation searching and contacting authors to identify
additional studies.
SELECTION CRITERIA: We considered two groups of participants: health
professionals involved in CPW utilization, including (but not limited to)
physicians, nurses, physiotherapists, pharmacists, occupational therapists and
social workers; and patients managed using a CPW. We included randomized trials,
non-randomized trials, controlled before-after (CBA) studies, and interrupted
time-series (ITS) studies comparing (1) stand-alone clinical pathways with usual
care, and (2) clinical pathways as part of a multifaceted intervention with
usual care.
DATA COLLECTION AND ANALYSIS: Two authors independently screened all titles,
abstracts and full-text manuscripts to assess eligibility and the methodological
quality of included studies using the Cochrane Effective Practice and
Organization of Care 'Risk of Bias' tool. Certainty of evidence was assessed by
two authors independently. Interventions were scored as 'high', 'moderate' or
'low' for the evidence-based implementation process.
MAIN RESULTS: The update provided 31 additional studies for a total of 58
included studies (24,841 patients and 2027 healthcare professionals). Forty-one
(71%) were randomized trials, four (7%) non-randomized trials, four (7%) CBA
studies and nine (16%) ITS studies. Forty-nine studies compared stand-alone CPWs
to usual care and nine compared multifaceted interventions including a CPW to
usual care. Collectively, the risk of bias was high due to potential
contamination by healthcare professionals, lack of blinding of patients and
personnel, lack of allocation concealment and selective reporting in ITS
studies. Stand-alone clinical pathway interventions It is uncertain whether
stand-alone CPWs reduce inhospital mortality (13% v 16%: OR 0.79, 95% CI 0.53 to
1.20; P = 0.27; I² = 65%; 7 randomized trials; n = 4603; low-certainty evidence
due to serious imprecision and inconsistency) or mortality (up to 6 months) (4%
v 3%: OR 1.37, 95% CI 0.72 to 2.60; P = 0.34; I² = 20%; 3 randomized trials, n =
805; low-certainty evidence due to serious risk of bias and imprecision).
Stand-alone CPWs likely reduce inhospital complications (10% v 17%: OR 0.57, 95%
CI 0.41 to 0.80; P = 0.001; I² = 52%; 11 randomized trials, n = 3668;
moderate-certainty evidence due to serious risk of bias). It is very uncertain
whether stand-alone CPWs reduce hospital readmissions (up to 6 months) (9% v
13%: OR 0.67, 95% CI 0.44 to 1.03; P = 0.07; I² = 11%; 9 randomized trials, n =
1578; very low-certainty evidence due to serious risk of bias and very serious
imprecision). Stand-alone CPWs likely reduce the length of hospital stay
compared to usual care (MD -1.12 days, 95% CI -1.60 to -0.65; P < 0.00001; I² =
64%; 21 studies; n = 5201; moderate-certainty evidence due to serious
inconsistency). Costs and charges were generally lower in CPWs as indicated by
negative MDs in nine studies (10 studies, n = 2113, data not pooled; very
low-certainty evidence due to serious indirectness and very serious
inconsistency). Stand-alone CPWs may slightly increase adherence to recommended
practice compared with usual care (3 randomized studies, n = 573; data not
pooled; low-certainty evidence due to serious risk of bias and serious
inconsistency). Multifaceted clinical pathway interventions It is uncertain
whether multifaceted CPWs reduce inhospital mortality (2 randomized studies, n =
6304, data not pooled; low-certainty evidence due to very serious
inconsistency). Multifaceted CPWs may make little or no difference to mortality
(up to 6 months) (9% v 8%: OR 1.05, 95% CI 0.88 to 1.25; P = 0.61; I² = 0%; 3
randomized studies; n = 6531; low-certainty evidence due to serious imprecision
and serious risk of bias). It is uncertain whether multifaceted CPWs reduce
inhospital complications (9% v 23%: OR 0.32, 95% CI 0.12 to 0.87; 1 study, n =
140; low-certainty evidence due to very serious imprecision). It is uncertain
whether multifaceted CPWs reduce hospital readmission (up to 6 months) (2
randomized studies, n =1569, data not pooled; low-certainty evidence due to very
serious inconsistency), or length of stay (4 randomized studies, n = 1936, data
not pooled; low-certainty evidence due to very serious inconsistency), or
hospital costs and charges (4 randomized studies, n = 2015, data not pooled;
very low-certainty evidence due to very serious imprecision and serious
indirectness in outcome measures). It is uncertain whether multifaceted CPWs
increase adherence to recommended practice (2 randomized studies, n = 6304, data
not pooled, low-certainty evidence due to very serious inconsistency). Key study
characteristics The highest proportion of included studies were from the USA
(36%), followed by Australia (10%), China (10%), Japan (5%), the UK (5%), Canada
(5%), Italy (5%), and Germany (5%). More than half of the included studies
tested CPW in general acute wards (53%), followed by emergency departments
(17%), intensive care (14%), and extended-stay facilities (10%). The most common
clinical conditions were asthma (16%), stroke (10%), mechanical ventilation (9%)
and myocardial infarction (7%).
AUTHORS' CONCLUSIONS: Stand-alone CPWs are likely to reduce inhospital
complications and length of hospital stay and may slightly increase adherence to
recommended practice. There was little conclusive evidence for multifaceted CPWs
due to mixed results from a limited number of included studies. It is uncertain
whether stand-alone CPWs or CPWs, as part of a multifaceted approach, reduce
inhospital mortality, mortality (up to 6 months), hospital readmission (up to 6
months) or costs and charges.
Copyright © 2025 The Cochrane Collaboration. Published by John Wiley & Sons,
Ltd.
DOI: 10.1002/14651858.CD006632.pub3
PMCID: PMC12076547
PMID: 40365866 [Indexed for MEDLINE]
Conflict of interest statement: Thomas Rotter (TR): Author of one of the
included studies. The evaluation of this study, including data extraction and
risk of bias assessment, was conducted by two other authors not involved in the
study. No other conflicts known. Leigh Kinsman (LK): Author of two of the
included studies. The evaluation of these studies, including data extraction and
risk of bias assessment, was conducted by two other authors not involved in
either of the studies. No other conflicts known. Agnes Alsius (AA): none known.
Shannon D. Scott (SS): none known. Adegboyega Lawal (AL): none known. Ulrich
Ronellenfitsch (UR): none known. Christopher Plishka (CP): none known. Gary
Groot (GG): none known. Phil Woods (PW): none known. Chloe Coulson (CC): none
known. Leigh Anne Bakel (LAB): none known. Kimberly Sears (KS): none known.
Amanda Ross‐White (ARW): none known. Andreas Machotta (AM): Author of one of the
included studies. The evaluation of this study, including data extraction and
risk of bias assessment, was conducted by two other authors not involved in the
study. No other conflicts known. Timothy J Schultz (TS): none known.
