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Archived Comments for: What is a clinical pathway? Development of a definition to inform the debate

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  1. Care Pathways are defined as complex interventions.

    Kris Vanhaecht, European Pathway Association (international not-for-profit association) (

    28 June 2010

    We hereby kindly would express our concerns about the paper by Kinsman et al on the definition of clinical pathways that was recently published in this journal (BMC Medicine 2010, 8:31 doi:10.1186/1741-7015-8-31) (1).

    We contact you as board members of the European Pathway Association (E-P-A) ( The E-P-A is an international not for profit association to support research and knowledge sharing on care pathways, with more than 670 members out of more than 50 countries worldwide.

    In this paper by Kinsman et al. the authors refer to our association and base their work on three papers of which two are published by some of our E-P-A-members. In table 1 of the paper an overview is provided of the Characteristics of clinical pathways derived from the three sentinel articles. We like to inform you that the paper by Vanhaecht et al. (2006) consists of 17 criteria and the paper by Debleser et al (2006) provides a detailed overview on how a definition of pathways could be built up (2;3). Kinsman et al define in their paper five criteria of clinical pathways but it is unclear how these five criteria were selected based on three publications.

    As recommended in the paper by Debleser et al, the E-P-A took the lead in international discussions on the definition of pathways based on the knowledge from this extensive literature review (3). Based on the results of this paper the association organized a consensus meeting with international experts on pathways in Slovenia in 2005 where a first draft of the E-P-A definition of care pathway was developed. Based on multicenter studies on pathways by Vanhaecht et al (2007) and cluster randomized trials by Panella et al. (2007) the E-P-A further revised the definition (4;5).

    Care pathways, of which the Medical SubHeading is still “critical pathway”, but commonly named in literature clinical pathway or care pathway, moved from “schedules of medical and nursing procedures” over “methods and tools” to “complex interventions”. The European Pathway Association nowadays defines a care pathways as “a complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period (6)”. Defining characteristics of care pathways include: (i) An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics; (ii) The facilitation of the communication among the team members and with patients and families; (iii) The coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; (iv) The documentation, monitoring, and evaluation of variances and outcomes; and (v) The identification of the appropriate resources. The aim of a care pathway is to enhance the quality of care, across the continuum, by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources (4;6).

    This definition was first published by Vanhaecht et al (2007) and later even cited in a meta-analysis published in this and other journals (BMC Medicine 2009, 7:32 doi:10.1186/1741-7015-7-32) (4;7). Recently an editorial in the International Journal of Care Pathways was covering this topic and explained why and how the E-P-A definition was developed (6). This definition is also the basis for the first international cluster randomized trial on care pathways, which is performed in Belgium, Italy, Ireland and Portugal (8).

    We are surprised that this definition is not mentioned in the paper by Kinsman et al. We are even more surprised reading that one of the reviewers of the paper explicitly suggests to do so.

    Our main concern is that the characteristics for the definition by Kinsman et al, as suggested in their paper, lead to even more misunderstandings and maybe even lead to inappropriate conclusions of their Cochrane review (9).

    We regret that the paper by Kinsman et al was not based on the most recently published knowledge on care pathways and hereby hope that we informed the readers of BMC Medicine.

    Dr. Kris Vanhaecht, Secretary General E-P-A
    Prof. dr. Walter Sermeus, board E-P-A
    Mr. Ruben Van Zelm, board E-P-A
    Prof. dr. Massimiliano Panella, President E-P-A

    Reference List

    (1) Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med 2010;8(31).
    (2) Vanhaecht K, De Witte K, Depreitere R, Sermeus W. Clinical pathway audit tools: a systematic review. J Nurs Manag 2006 Oct;14(7):529-37.
    (3) De Bleser L, Depreitere R, Waele KD, Vanhaecht K, Vlayen J, Sermeus W. Defining pathways. J Nurs Manag 2006 Oct;14(7):553-63.
    (4) Vanhaecht K, De Witte K, Sermeus W. The impact of clinical pathways on the organisation of care processes. Leuven: ACCO; 2007.
    (5) Panella M, Marchisio S, Gardini A, Di Stanislao F. A cluster randomized controlled trial of a clinical pathway for hospital treatment of heart failure: study design and population. BMC Health Serv Res 2007;7:179.
    (6) Panella M, Vanhaecht K. Is there still need for confusion about pathways? International Journal of Care Pathways 2010;14:1-3.
    (7) Barbieri A, Vanhaecht K, Van Herck P., Sermeus W, Faggiano F, Marchisio S, et al. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 2009 Jul 1;7(1):32.
    (8) Vanhaecht K, Sermeus W, Peers J, Deneckere S, Lodewijckx C, Leigheb F, et al. The European Quality of Care Pathway (EQCP) Study: history, project management & approach. International Journal of Care Pathways 2010;14(2):52-6.
    (9) Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010;Art. No.: CD006632.

    Competing interests

    no competing interests

  2. European Pathways Association definition is unusable

    Leigh Kinsman, Monash University

    26 August 2010

    Thank-you for the comments from Vanhaecht et al. (on behalf of the European Pathways Association [E-P-A]) regarding our correspondence.
    A major aim of our paper was to generate discussion regarding a usable definition for clinical pathways (CPWs). Therefore we are pleased that discussion has been generated towards redressing the confusing definitions for a CPW. The definition promoted by the E-P-A is well-considered, accurate and inclusive. It reflects a high degree of academic rigour. However, it lacks the specificity to guide a literature search strategy, and the objectivity to maximise agreement between readers on whether an intervention is, or is not, a CPW.
    Our criteria were developed a-priori for an extensive Cochrane Collaboration systematic review and established as a component of our protocol published in 2007 (1). The most recent work cited by Vanhaecht et al. could not be included, but would not have been usable for identifying literature or maximising co-author agreement on what constitutes a CPW. This issue confronts clinicians, researchers, healthcare managers and policy-makers on a daily basis when trying to make evidence-informed decisions about CPWs. They cannot be confident that their search will include all key research pertaining to CPWs.
    We challenge the E-P-A to use their substantial knowledge, expertise, network and resources to simplify their consensus definition.

    Leigh Kinsman and Thomas Rotter

    1. Rotter T, Koch R, Kugler J, Gothe H, Kinsman L, James E. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2007, Issue 3.

    Competing interests

    No competing interests exist.