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Validating the Concept of Patient Pathways: A European Survey on Their Characteristics, Definition and State of Practice

Authors:
  • Research Group Digital Health at Technische Universität Dresden

Abstract

Patient pathways (PPs) are considered a valuable instrument for managing integrated, patient-centred healthcare services. Still, a uniform understanding and definition of PPs is lacking, leading to misunderstandings and inconsistent use in both science and practice. Accordingly, the objective of this paper is to assess the practical view of PP stakeholders on characteristics, a definition and current implementation practice. Building on the findings of a previous systematic scoping review, a questionnaire was developed, tested and applied in the domain of cancer care. The findings show broad acceptance of the PP characteristics surveyed. The initial PP definition was revised using respondents’ suggestions for modification. Existing diversity in practical PP usage is identified, but high expectations regarding positive impacts on care delivery are confirmed. Further work will continue the validation in other healthcare domains of complex, chronic diseases. This work contributes to drive PP implementation by shedding light on the perspective of practice.
Validating the Concept of Patient Pathways in Practice
Twenty-fifth Pacific Asia Conference on Information Systems, Dubai, UAE, 2021
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Validating the Concept of Patient Pathways: A
European Survey on their Characteristics,
Definition and State of Practice
Research-in-Progress
Peggy Richter
Technische Universität Dresden
Dresden, Germany
peggy.richter2@tu-dresden.de
Emily Hickmann
Technische Universität Dresden
Dresden, Germany
emily.hickmann@tu-dresden.de
Hannes Schlieter
Technische Universität Dresden
Dresden, Germany
hannes.schlieter@tu-dresden.de
Abstract
Patient pathways (PPs) are considered a valuable instrument for managing integrated,
patient-centred healthcare services. Still, a uniform understanding and definition of
PPs is lacking, leading to misunderstandings and inconsistent use in both science and
practice. Accordingly, the objective of this paper is to assess the practical view of PP
stakeholders on characteristics, a definition and current implementation practice.
Building on the findings of a previous systematic scoping review, a questionnaire was
developed, tested and applied in the domain of cancer care. The findings show broad
acceptance of the PP characteristics surveyed. The initial PP definition was revised
using respondents’ suggestions for modification. Existing diversity in practical PP
usage is identified, but high expectations regarding positive impacts on care delivery
are confirmed. Further work will continue the validation in other healthcare domains
of complex, chronic diseases. This work contributes to drive PP implementation by
shedding light on the perspective of practice.
Keywords: Care process, definition, integrated care network, patient pathway, survey
Introduction
The challenges of western healthcare systems - such as a growing and ageing population, an increase
of chronic and complex diseases, and at the same time skilled worker shortages and increasing costs of
care delivery - demand for integrated, patient-centred care in form of coordinated, synergetic care
provision in a network of health service providers (Lerum and Frich, 2012; Nolte and Pitchforth, 2014).
Integrated care is a concept seeking to manage a patient’s entire continuum of care throughout different
healthcare sectors and phases by using techniques and organisational models designed to implement
connectivity, alignment and collaboration (Kodner and Spreeuwenberg, 2002; World Health
Organization, 2016). In relation to this, patient-centred care, i.e. viewing and empowering patients to
be competent co-managers of their own care process and well-being, became a declared goal of health
policy (Castro et al., 2016; Kayser et al., 2019).
Integrated care networks support the implementation of integrated care on organisational level. Being
socio-technical systems, they hold diverse opportunities for information systems research, addressing
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issues of its three object types, which are people, information and communication technologies, and
organisational concepts (Österle et al., 2011). In terms of the latter, the concept of patient pathways
gained increasing attention in literature over the last years (Richter and Schlieter, 2019). For example,
in cancer care with cancer being one of the most common and costly diseases in western countries
(Banks et al., 2010), patient pathways are recognised as a valuable approach to support seamless care,
patient information as well as the implementation of medical guideline recommendations in
comprehensive cancer care networks (CCCNs) (Albreht et al., 2017). Still, there is no common
definition or conceptualisation of patient pathways available. This makes it difficult to comprehensively
measure their impact on managing the challenges described above as well as expected benefits such as
quality improvements or guideline implementation. Also, it leads to inconsistent understanding and use
of the term in both science and practice.
Starting to unravel the concept of patient pathways, a scoping review was conducted in a previous study
by two of the authors (Richter and Schlieter, 2019). Although no uniform definition of patient pathways
could be identified in literature, the scoping review allowed for the derivation of descriptive
characteristics. These cover the goals, focus, usage, scope, stakeholders, and development of patient
pathways. The study results highlight, that patient pathways describe an independent pathway approach
adapting and extending characteristics of other well-known pathway concepts such as care pathways or
clinical pathways (De Bleser et al., 2006; Leigh Kinsman et al., 2010; Schrijvers et al., 2012). Two
main aspects of patient pathways, that clearly distinguish them from other pathway concepts are that
they cover the whole journey of a defined patient type, (i.e. interorganisational and intersectoral
care provided by an interdisciplinary network of care providers) and that
they have a strong patient focus, becoming apparent for example through an incorporation of
the patients’ perspective as well as elements of patient engagement and empowerment (Richter
and Schlieter, 2019).
In order to validate the characteristics of patient pathways identified from literature, the objective of
this paper is to match the state of the art with the state of the practice to drive agreement and acceptance
of a uniform definition forward. To assess the view of the practice, i.e. the view of patient pathway
stakeholders on characteristics and a definition of the concept, a survey questionnaire is developed and
tested. With the results of such a survey, a foundation for comprehensive impact measurement and a
contribution to an increased exploitation of patient pathways in integrated care networks could be
achieved. Hence, this paper addresses the following three research questions (RQ).
(RQ1) To what extent do patient pathway stakeholders agree with the characteristics identified
based on literature?
(RQ2) To what extent do patient pathway stakeholders agree with a proposed definition of
patient pathways derived from the literature?
(RQ3) What are practical experiences with patient pathway implementation in integrated care
networks?
The remainder of this work is structured as follows. In the method section, the method used is described,
i.e. the development and testing of a patient pathway questionnaire to assess the understanding,
experiences and state of patient pathway practice among relevant stakeholder groups. In the results
section, the survey results of the application of the questionnaire in the domain of comprehensive cancer
care are presented, addressing the three research questions in individual subsections. The results are
discussed and the paper closes with a conclusion and an outlook on further research planned.
Method
Based on the characteristics of patient pathways identified with our previous literature study (Richter
and Schlieter, 2019), we developed a questionnaire to assess the agreement and view of patient pathway
stakeholders. Health service providers of all units/institutions involved in care delivered by an
integrated care network are relevant patient pathway stakeholders to be included in the study. These
comprise members of the care network itself (i.e. units dedicated to prevention, diagnosis, treatment,
follow-up care, supportive care, palliative care, rehabilitation, or research), healthcare organisations
(e.g. accreditation organisations, multi-disciplinary multi-stakeholder organisations), policy (e.g.
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national authorities, policy developer or advisor), pathway methodologists, technical experts, as well as
patients or patient representatives. The developed questionnaire covers three parts, which are:
1. Characteristics of patient pathways. The first part of the questionnaire contains questions
asking for the agreement of survey participants with statements derived from the literature to
describe patient pathways (using a 5-point Likert scale). The areas of interest covered are the
purpose of use, focus, development, and user groups. Missing characteristics can be proposed
using a comments field.
2. Definition of patient pathways. The second part includes the question, if a proposed general
definition of patient pathways covers the understanding of the participants. Changes to the
definition can be suggested using a comments field. Additionally, synonym terms for patient
pathways used in practice are surveyed.
3. Patient pathway practice. This third part of the questionnaire addresses practical experiences
of the respondents in terms of general involvement with patient pathways. Furthermore,
common representation formats used in practice are explored as well as potentials of patient
pathway usage for integrated care networks (and vice versa).
To test the questionnaire, we applied it in the domain of integrated cancer care. Therefore, questions
were adapted to the common terminology of the field e.g. by using the specific term “comprehensive
cancer care network” instead of the general term “integrated care network”. A pre-test with domain
experts from Luxembourg (National Cancer Institute) and Germany (German Cancer Society) was
conducted, resulting in the rewording of some questions. The final questionnaire
1
was provided online
and the survey invitation was sent to the patient pathway working group of the European Joint Action
iPAAC (Innovative Partnership for Action Against Cancer)
2
. This working group comprises patient
pathway stakeholders in the domain of oncology care from all relevant groups, i.e. experts involved in
cancer cure and care along all phases of the care process, research, network management and
certification, European and national cancer organisations, national health ministries, as well as
representatives of European cancer patient organisations. In total, 19 fully completed questionnaires
were received and evaluated. In case not all participants answered a question or multiple answers were
possible, the number of responses is depicted separately (n = …) in the following section.
Survey Results in the Domain of Comprehensive Cancer Care
Characteristics of Patient Pathways
When considering the purpose of patient pathway usage, it can be summarised that most participants
broadly accepted the findings from literature (see Figure 1). Especially, the perspective that description
and organisation of the key care provision phases is a main purpose of patient pathways was agreed
upon by all respondents. Evaluation and monitoring were generally also confirmed as purposes, which
patient pathways should fulfil. The intension, that they should be used for documentation as well as
engagement of patients raised some more critical voices, however, the large majority (84 %) strongly
agreed or agreed.
None of the respondents disagreed with any of the characteristics of patient pathways found in literature.
Accordance was highest with the statement that patient pathways should take disease-related goals of
care into account. Furthermore, the planning and management of individual patients and patient groups,
as well as the consideration of organisational goals were supported by a large proportion (84 %) of the
consortium members. Only the focus of patient pathways on individual treatment preferences of patients
resulted in a neutral position by a comparably large number (32 %) of participants (see Figure 2).
1
The final patient pathway questionnaire can be provided by the authors on request.
2
Project website: https://www.ipaac.eu/ (last accessed: 28.05.2021)
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Figure 1. Purpose of patient pathway usage.
Figure 2. Focus of patient pathways.
Findings in literature on patient pathway development were also evaluated. All respondents complied
that medical evidence and experts experience should be considered during the process. Approval for
the development of patient pathways in a multidisciplinary team was also very high. The patient
engagement aspect (i.e. integration of the patients’ perspective during pathway development) again lead
to a high proportion of participants (37 %) who neither agreed nor disagreed with the statement.
When considering the users of patient pathways, broad accordance was reached regarding professional
care providers, as well as social services. More critical points of view appeared when shifting the focus
on patients and their relatives as patient pathway users (see Figure 3).
11
13
3
7
10
5
5
10
9
6
3
1
6
3
3
Organisational goals
of care
Disease-related
(medical) goals of care
Individual treatment
preferences of patients
Patient group
planning/management
Individual patient
planning/management
A pa t ie n t pathw ay sh o uld co n s ide r...
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
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Figure 3. User groups of patient pathways.
When asked about additional characteristics of patient pathways, the specific role of non-profit
organisations as well as a focus on the continuity and integration of care across a network and between
diverse levels of care, were brought to attention by the respondents of the cancer care domain.
Definition of Patient Pathways
Based on the findings of the previously conducted scoping review (Richter and Schlieter, 2019), we
proposed the following definition of patient pathways to the survey participants. “A patient pathway is
a tool to plan and manage the care process of patient groups with complex, long-term conditions to
support mutual decision-making by a multidisciplinary care team and patients.” This definition was
broadly supported by the survey participants with 89 % answering “yes” to the question, if their
understanding of patient pathways is represented with this definition. Participants were asked to suggest
modifications if the definition did not represent their understanding (which was the case for 11 % of the
participants). Comments included highlighting the network-view of patient pathways, stressing their
evidence base, or detailing their main components.
Survey participants were also asked about how the term patient pathway is understood in their working
environment. The answers reveal, that when the term is in practical usage, only in 47 % of the cases,
the working environments understand and utilise patient pathways as intended with the proposed
definition. The following comments given by survey participants exemplarily represent the diverse
understanding and use of patient pathways in the domain of cancer care.
Some medical units employ the patient pathway by informal agreements between specialists
and clinics, but no standards of care are applied. Also, most of pathways used are based on
expert opinions. No national guidelines are developed or used.
It is understood but seldomly used for structuring care practices. A similar term is individual
care plan, which is much less comprehensive.
“The terms ‘patient pathway’ and ‘clinical pathways’ are sometime used interchangeably, but
often carry different meaning attached.
It could also be understood as document/information for patients, comparable to the term
guidelines. There are guidelines written for healthcare professionals and patient guidelines
written especially for patients.
The survey participants were asked, which other terms, identified and proposed based on the literature
findings, are used synonymously for the patient pathway concept as described and defined before. With
multiple answers allowed, care pathway (21 % of n = 38 answers), integrated care pathway (21 %),
clinical pathway (24 %), treatment pathway (13 %), patient journey (13 %), and care map (2 %) were
selected. Other terms (6 %), added by the participants using the comments field, are patient navigation,
individual care plan, and fast track/treatment.
15
9
6
6
4
7
8
6
3
3
4
2
3
All involved
professional
care providers
Social
services
Patients
Patient
relatives
A p a t ie nt pat h w ay sh o uld be used by...
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
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Patient Pathways in CCCNs
Respondents of the questionnaire are involved very differently with patient pathways and their
implementation in CCCNs. Next to leaders and care coordinators of specific pathways in the networks,
many are also involved in the developmental process. Here, the creation of an overall strategic policy,
the incorporation of guidelines and the creation of specific internal mechanisms (for example to
accelerate the treatment process of cancer patients) in pathways are discussed. Many practitioners are
also involved in quality management and assurance of patient pathways. Comments show that in
practice, implemented patient pathways are often used as a tool for the certification of CCCNs.
When considering presentation formats of patient pathways adopted in the implementation process,
results show that no uniform standard has been adopted in practice. Process models, for example flow
charts, UML (Unified Modeling Language) activity diagrams or BPMN (Business Process Model and
Notation) models, were the most common (see Figure 4). The category “other” included combinations
of the named presentation formats, especially process models combined with prosaic descriptions.
Figure 4. Presentation formats of patient pathways (n = 28).
Practical experiences of the participants support the perception that patient pathway implementation
and usage can have multiple benefits for CCCNs. A large majority of survey participants agreed to
findings in the literature that an improved care coordination (89 %) and an improved quality of care
(72 %) as the main advantages of patient pathways (multiple answers were possible). Additionally, their
implementation is perceived as a promising tool to increase standardisation of care, compliance with
standards and patient satisfaction (i.e. feeling of safety).
On the other hand, CCCNs could also support the application of patient pathways in practice. For
example, many participants confirmed that methodological (61 %) and technological (67 %) support,
as well as the encouragement of patient involvement (33 %) during patient pathway development and
implementation are great potentials of CCCNs. Additionally, the networks can function as good practice
examples and ensure a centralised management of patient pathways. The consistent evaluation of patient
pathway usage through CCCNs, in combination with continuous quality improvement, was another
potential added by participants.
Discussion
The results obtained reflect a high conformity between the characteristics found on patient pathways in
literature and their understanding in cancer care practice. Generally, few respondents disagreed or
strongly disagreed with any of the statements in the areas of interest. However, it can be noted that
respondents tended to have a rather neutral position (neither agreeing nor disagreeing) about patient
engagement aspects which is somehow contrary to the increasing demand for patient-centred care in
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terms of actively involving and empowering patients as co-managers of their own health journey
(Kayser et al., 2019; Parker, 1999). This could be noted when considering the focus, the development
and the users of patient pathways. The statement “A patient pathway should consider individual
treatment preferences for patients” resulted in 32 % of participants answering neutrally and 37 % of the
consortium members neither agreed nor disagreed with the integration of the patients’ perspective
during pathway development. Furthermore, when patients or patient relatives were considered as
pathway users, a comparably high percentage of responders (37 % and 26 %) had no opinion or even
disagreed. This potential gap between patient engagement activities proposed in literature and their
implementation and acceptance in practice should therefore be explored further.
Furthermore, a high conformity between the general definition of patient pathways derived from
literature and its understanding by the survey participants could be distinguished. The comments made
by the respondents were used to revise the proposed definition. Based on this, the following definition
of patient pathways is suggested to be used for further studies in other domains of care: A patient
pathway is an evidence-based tool that supports the planning and management of the care process of
individual patients within a group of similar patients with complex, long-term conditions. It details the
phases of care, guiding the whole journey a patient takes by defining goals and milestones, and supports
mutual decision-making by the patient and his/her multidisciplinary care team collaborating in a
comprehensive network of care providers.
Interestingly, when asked if the definition is also understood and used in this manner in the respective
working environments, only 47 % of participants agreed. When considering this finding and the
comments made by the respondents, a terminological standard seems to be missing in practice. This is
the case even though a general understanding (at least in the domain of cancer care) on the term patient
pathway was reached for 89 % of participants. To implement patient pathways in integrated care
practice, terminological and methodological consensus seems to be essential. Providing standardised
methodological support for patient pathway development and implementation could reduce complexity
and further exploit their potentials.
Conclusion and Further Research
In summary, patient pathways as an organisational concept of healthcare networks on process level
prove to be of value to cope with today’s challenges faced by western healthcare systems. This work
functions as a starting point for a broad validation of the state of the art and practice of patient pathways.
It informs the debate on patient pathways and sheds light on descriptive characteristics of this concept
as well as on existing solutions and desirable advances for integrated care networks in terms of their
utilisation. Both the potentials and complexity of the patient pathway approach were confirmed.
In this paper, a questionnaire to assess the perspective of patient pathway stakeholders on characteristics
and a definition of the concept as well as the state of practical implementation was developed, based on
findings of a previously conducted literature analysis. The questionnaire was applied in the domain of
comprehensive cancer care and was answered by experts across Europe. The analysis of the results with
regard to RQ1 show high conformity between patient pathway characteristics identified in the literature
and their understanding in practice. Interestingly, a strong patient engagement during patient pathway
development and decision-making raised some critical voices among the respondents. Answering RQ2,
the proposed definition of patient pathways was broadly supported and suggestions for modification
were incorporated to provide a more validated and comprehensive definition. With regard to RQ3, the
results of applying the survey in the domain of cancer care illustrate existing diversity in the practical
application and usage of patient pathways. However, it was broadly confirmed that they are a promising
tool for CCCNs to increase standardisation and to improve quality of care and care coordination. Also,
care networks are considered a beneficial environment for patient pathway utilisation, e. g. by providing
seamless care, by offering good example input for patient pathway development, and by providing
technological and methodological support.
In future work, the validation started in cancer care is to be continued in other healthcare domains and
outside of Europe. It will especially include experts in the field of integrated care provision for chronic
and complex diseases, e. g. stroke care, diabetes, and neurodegenerative diseases. Therefore, the
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questionnaire will be adapted to the specifics of these care domains as was done for the survey among
experts of comprehensive cancer care. The objectives of such broader evaluation are (1) to clearly
distinguish the concept and assess the idea and understanding of patient pathways in integrated care
networks in general, (2) to assess their potentials for implementation and the state of the practice, (3) to
assess in which domains the concept might already be established to learn from their successful
examples, (4) to validate the revised patient pathway definition, and (5) to avoid bias stemming from
the initial focus on cancer care in Europe. This will contribute to a uniform conceptualisation of patient
pathways. The results can build the foundation for comprehensive impact measurement in terms of care
quality provided by an integrated, patient-centred network of interdisciplinary care providers.
Acknowledgements
This article was funded by the European Union’s Health Programme (2014-2020). We thank the patient
pathway working group of the iPAAC WP10 for their continuous support. Special thanks go to PD Dr.
med. Simone Wesselmann and her colleagues from the German Cancer Society as well as to Dr. Nikolai
Goncharenko from the National Cancer Institute, Luxembourg for pre-testing the questionnaire.
References
Albreht, T., Kiasuwa, R., Van der Bulcke, M. (eds.) 2017. EUROPEAN guide on quality improvement
in comprehensive cancer control, CanCon - Cancer Control Joint Action,” Ljubljana: National
Institute of Public Health; Brussels: Scientific Institute of Public Health.
Banks, J., Muriel, A., Smith, J.P. 2010. Disease prevalence, disease incidence, and mortality in the
United States and in England,” Demography (47), pp. S211-S231.
Castro, E.M., van Regenmortel, T., Vanhaecht, K., Sermeus, W., van Hecke, A. 2016. Patient
empowerment, patient participation and patient-centeredness in hospital care: A concept analysis
based on a literature review,” Patient Education and Counseling (99:12), pp. 1923-1939.
De Bleser, L., Depreitere, R., De Waele, K., Vanhaecht, K., Vlayen, J., Sermeus, W. 2006. Defining
pathways,” Journal of Nursing Management (14), pp. 553-563.
Kayser, L., Karnoe, A., Duminski, E., Somekh, D., Vera-Muñoz, C. 2019. A new understanding of
health related empowerment in the context of an active and healthy ageing,” BMC Health Services
Research (19), 242.
Kodner, D.L., Spreeuwenberg, C. 2002. Integrated care: meaning, logic, applications, and implications
a discussion paper,” International Journal of Integrated Care (2), e12.
Kinsman, L., Rotter, T., James, E., Snow, P., Willis, J. 2010. What is a clinical pathway? Development
of a definition to inform the debate,” BMC Medicine (8), pp. 31-33.
Lerum, S.V., Frich, J.C. 2012. Normative assumptions in integrated care: A conceptual discussion,”
International Journal of Healthcare Management (5), pp. 32-39.
Nolte, E., Pitchforth, E. 2014. What is the evidence on the economic impacts of integrated care?,”
Policy Summary 11, World Health Organization.
Österle, H., Becker, J., Frank, U., Hess, T., Karagiannis, D., Krcmar, H., Loos, P., Mertens, P.,
Oberweis, A., Sinz, E.J. 2011. Memorandum on design-oriented information systems research,”
European Journal of Information Systems (20), pp. 7-10.
Parker, C. 1999. Patient pathways as a tool for empowering patients,” Nursing Case Management (4),
pp. 77-79.
Richter, P., Schlieter, H., 2019. Understanding Patient Pathways in the Context of Integrated Health
Care Services - Implications from a Scoping Review, in Proceedings of the 14th International
Conference on Wirtschaftsinformatik, Siegen, Germany, 2019, pp. 9971011.
Schrijvers, G., van Hoorn, A., Huiskes, N. 2012. The care pathway: concepts and theories: an
introduction,” International Journal of Integrated Care (12), e192.
World Health Organization 2016. Framework on integrated, people-centred health services,” Report
by the Secretariat (No. Sixty-ninth World Health Assembly. Provisional agenda item 16.1).
ResearchGate has not been able to resolve any citations for this publication.
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