Using care pathways
to improve health systems
Care pathways enable health systems (and other health care organizations) to make evidence-based decisions about where to focus improvement efforts.
Olivia Cavlan, MD;
One of the core missions of any health
care for more severely ill children, and palliative Penny Dash, MD;
system is to improve the health status of its
care for the terminally ill.
Jean Drouin, MD;
population. To do this, it must take appropriate Tim Fountaine,
actions to prevent illness as well as to ensure the Both types of care pathways rely heavily on MD, PhD; and
efficient delivery of high-quality primary, sec- clinical evidence. As a result, clinicians tend Farhad Riahi, MD
ondary, tertiary, and rehabilitative care. Select- to find them intuitive to use. And because clini- ing which interventions to prioritize can be dif- cians are intimately involved in the pathways' ficult, however. It can be even more difficult to creation, they often become champions of the determine how to set up the health system to en- resulting recommendations for change.
sure that the appropriate interventions are deliv-ered efficiently. In this article, we focus on the use of disease-specific care pathways. We describe why these To address these problems, many leading health pathways can be so valuable and outline how systems (and the payors and providers within they are developed. In addition, we provide them) are adopting a new approach based on several case examples of how health systems care pathways to map the steps in a patient's have used disease-specific pathways to improve journey through the entire health system. The care quality, reduce costs, or both. pathways are organized by the stages of care (from prevention and primary care to acute care Why the pathway approach is useful
and rehabilitation) and include the full range To understand why the pathway approach can be of interventions that may be offered at each so useful, consider a health system with a finite stage. Because the pathways are based on the budget (realistically, any health system today) best available clinical evidence, they enable that wants to improve outcomes in CHD. Among health systems to determine the interventions' the questions it might need to consider are these: relative importance, prioritize how resources Should it increase its investment in primary are allocated, and identify the outcome metrics prevention or build more catheterization labs? that will help ensure optimal care delivery. If it opts for primary prevention, which strategies should it focus on first? Alternatively, if it decides Some pathways focus on specific diseases, such to build cath labs, where should the labs be as diabetes or coronary heart disease (CHD); located, and what support services need to these pathways include all treatments, from be in place to ensure that appropriate patients primary prevention to rehabilitative services, receive prompt treatment? that may be offered to patients with those diseases. However, a care pathway can also To answer such questions effectively, the health cover a group of conditions with similar treat- system must be able to identify all the inter- ment requirements, such as chronic diseases, ventions that can be used to prevent or treat or even a phase of life (e.g., pregnancy); in these CHD. The system must also know four things cases, the pathway maps the clinical steps taken about each intervention: its efficacy, its cost, at each stage of care. The pediatric care pathway, how and where it can best be delivered, and for example, includes routine vaccinations and what services and structures must be in place other well-child services, primary and commu- to ensure optimal de livery. Data on efficacy nity care services for sick children, specialist and cost allow the system to determine which Health International 2011 Number 11
interventions have the highest value — those Care pathways are much more comprehensive that provide the greatest benefit (in terms of than the tools that most health care organiza- clinical outcomes) per unit of cost. The other tions have traditionally relied on. For example, two sets of information enable the system to they provide greater depth than the evidence- determine how to deliver the prioritized inter- based guidelines (sometimes called clinical ventions efficiently to appropriate patients. pathways) that have been developed by various professional groups to describe best practices Care pathways include all four of these sets in care. Although these guidelines often offer of information; thus, they provide the breadth enormous assistance to clinicians providing and depth of information needed for good treatment to specific patients, they generally decision-making. For example, they make it include little or no information about costs, easier for health systems to make balanced optimal settings of care, or supporting services trade-offs among com pet ing priorities and and structures. Thus, they provide only limited to develop greater insights into where im- insights to health systems looking to define provement efforts should be focused. value or reconfigure service delivery.
Case study:
Several years ago, the National Health Service (NHS) in NHS London therefore decided that its primary goal London realized that stroke was placing a heavy burden would be to reconfigure its acute-care stroke services. Using a care
on its population. More than 11,000 Londoners suffered NHS London established eight hyper-acute stroke units strokes each year.1 The death rate from stroke was higher (HASUs), which were strategically situated to ensure to improve
in the greater London region than in surrounding areas of that all residents could get access to high-intensity care stroke care
England, and there were significant differences in stroke within 30 minutes.
prevalence and death rates within the city itself. NHS London therefore convened a panel of leading clinicians, In addition, it set up a network of secondary stroke units who helped it map the stroke pathway to determine where in hospitals throughout London to provide post-acute it most needed to improve. care. Stroke patients would remain in the HASUs until their condition stabilized (typically, about three days); Results showed that there were considerable differences they would then be transferred to a secondary stroke in the availability of rehabilitative services throughout the unit for rehabilitation and ongoing treatment.
city. But by far the biggest problem London faced was that it had fallen behind other major cities — and much of the Results were dramatic, even within the first year. All eight rest of England — in its ability to provide appropriate of London's hospitals with HASUs now rank in the top acute-care services for stroke patients. Few of its hospitals quartile of English hospitals on stroke care. The percentage had the specialist staff and equipment needed to provide of London's stroke patients given thrombolysis has more high-quality stroke care around the clock. Furthermore, than tripled, and in-hospital mortality rates among stroke most strokes occurred in London's outer boroughs, yet the patients have declined. Furthermore, the percentage of 1 Healthcare for London. London Stroke Strategy. 2008.
hospitals with specialist services tended to be in the city's stroke survivors being tested for residual dysfunction within 2 Unpublished data obtained center. Consequently, only about half of London's stroke three days has risen significantly. Yet overall length of stay from NHS London. October 2010.
patients received treatment in a dedicated stroke unit.
has decreased by about 20 percent.2 Using care pathways to improve health systems Best-practice interventions are mapped to each pathway stage
Acute care
Cardiac rehab/secondary prevention
Regular medication and monitoring from primary care
• Treat patients with hypertension (target blood pressure: ≤130/80 mm Hg)
• Treat patients with diabetes (target: HbA1c ≤7.0% or other national standard)
• Treat patients with statins on a long-term basis
• Prescribe sublingual nitroglycerin for immediate relief of angina
• Treat patients with beta-blockers on a long-term basis
• Treat patients with low-dose aspirin (75–325 mg/d) on a long-term basis
• Immunize patients against influenza
• Perform an annual GP review
Further assessment and treatment from specialist care
• Refer newly diagnosed angina patients to specialist for further assessment
• Perform exercise tolerance testing (i.e., stress ECG) for patients with • Perform angiography (± PCI) for high-risk patients identified by noninvasive • Perform coronary artery bypass grafting for angina patients with left-main-stem or triple-vessel disease CHD, coronary heart disease; ECG, electrocardiogram; GP, general practitioner; HbA1c, glycosylated hemoglobin (a measure of blood glucose control); PCI, percutaneous coronary intervention.
A few evidence-based guidelines focused on Using a disease-specific
narrow slices of care delivery, such as the in- hospital management of acute myocardial infarc- Three steps are required if a health system wants tion (AMI), do include some aspects of service to use a disease-specific care pathway effectively. configuration in their discussions. And some First, the system must assemble the fact base hospitals have taken cost and service config ur- so that it can design the pathway and prioritize ation into account in their efforts to improve interventions. Second, it must determine when, care delivery (for example, when attempting to where, and how the prioritized services can optimize use of their emergency departments best be delivered. Third, it must identify which or operating rooms). However, efforts such as "enablers" should be in place — the supporting these deal with only a single part of the patient's services and structures required to deliver the journey; thus, they do not include the full range services efficiently. Taken together, this informa- of information needed to clarify how different tion allows the health system to determine what parts of a health system can best work together.
changes it needs to make, how those changes Health International 2011 Number 11
Case study:
London's aim in developing its stroke pathway was not to early management was crucial from both a clinical and reduce the cost of stroke care, but rather to improve the an economic perspective; thus, the DMPs stipulated that Using care
quality of that care as efficiently as possible. Germany has all care would be coordinated by a single provider (usually, pathways
used care pathways both to improve care quality and to a general practitioner). for multiple
control costs.
Although all public payors are required to offer DMPs, A decade or so ago, the country discovered that about not all have been equally enthusiastic about doing so. 80 percent of its health system's costs were being spent Furthermore, patient enrollment in the programs is to provide care for only about 20 percent of its citizens, voluntary, and some experts have argued that voluntary most of whom had chronic conditions. Germany also participation has skewed the results achieved. Neverthe- realized that there were wide variations in the care being less, the initial results are promising. About 6.75 million delivered to patients with these conditions. To address Germans have enrolled since the first program (for type 2 both issues, it decided to change the way it funded its diabetes) was launched.1 A study of one large payor's type public payors, which together cover about 90 percent 2 diabetes DMP found that enrolled patients were less 1 Data released by the Bundes- verwaltungsamt (German Fed- of the population. Germany gave the payors extra funding likely to suffer disease complications, had a lower mortality eral Office of Administration). to encourage them to provide better care for patients rate, and incurred lower health care costs.2 A second large 2 Stock S et al. Germany diabetes with chronic conditions. But it also insisted that the payors study found that patients in DMPs for type 2 diabetes, management programs improve offer disease management programs (DMPs) to patients CHD, heart failure, or COPD experienced decreased hospital quality of care and curb costs. Health Affairs. 2010;12:2197- with six very common conditions (asthma, breast cancer, admission rates following program enrollment, whereas coronary heart disease [CHD], chronic obstructive pulmo- control patients had increased admission rates.3 Other 3 Hamar B et al. The impact of a proactive chronic care nary disease [COPD], type 1 diabetes, and type 2 diabetes). studies have also suggested that the DMPs help lower management program on Its goal was to increase adherence to best practices and mortality rates.4 hospital admission rates in a German health insurance contain costs.
society. Popul Health Manage. Not every payor has achieved equally strong results; 4 Versorgungs-Report 2011. The DMPs were based on care pathways built by panels of however, most of the programs have demonstrated Wissenschaftliche Institut experts, who identified best practices for each condition. improvements in processes of care and patient satisfaction, der AOK (Scientific Institute of the AOK). November 2010.
For many of the selected conditions, it became clear that and many are reporting better clinical outcomes.
should be implemented, and what timetable for done to lower a man's risk of prostate cancer. implementation is realistic.
The first stage in the prostate cancer pathway, therefore, is detection. Assembling the fact base The health system should begin by defining The next step is to add the interventions that the appropriate stages of the pathway. For should be included within each stage (Exhibit 1). example, a number of approaches can be Best-practice interventions are identified from used to help patients lower their risk of CHD a detailed scan of clinical guidelines, the peer- or stroke; thus, primary prevention is the first reviewed literature, and expert opinion. For each stage in the clinical pathways for those condi- intervention, the health system must determine tions. In contrast, comparatively little can be the clinical benefits it provides, the strength of Using care pathways to improve health systems Process and outcome metrics assess health system performance
Prevention of complications
Management of complications
Process metrics
• Percentage of diabetic patients with HbA1c ≤7 (or other national standard)
• Percentage of diabetic patients receiving annual retinopathy screening
• Percentage of diabetic patients receiving annual foot exams
• Percentage of diabetic patients receiving annual cholesterol screening
• Percentage of diabetic patients receiving annual urine microalbumin
excretion screening • Percentage of diabetic patients receiving annual blood pressure Outcome metrics
• Prevalence of retinopathy
• Prevalence of foot ulcers
• Prevalence of elevated microalbumin levels
• Prevalence of elevated cholesterol levels
• Prevalence of elevated blood pressure
• Prevalence of neuropathy
HbA1c, glycosylated hemoglobin (a measure of blood glucose control).
those benefits, the types of patients most likely current delivery costs may be much higher to benefit, and the cost of achieving those than what could be achieved if services were results. It is this combination of data that makes reconfigured to improve efficiency. These types the care pathway approach so helpful for health of differences should be taken into account systems — the inclusion of both quality and cost when the pathway's interventions are being dimensions enables practical decision-making. It is important, however, that an intervention's Another important step in assembling the fact benefits and costs be considered from two base is to determine which clinical outcomes are perspectives: what is theoretically possible most important to measure at each stage of the and what actually occurs. For example, patient pathway. For example, the most important out- compliance with treatment is often higher in come metric for the primary prevention of the carefully controlled clinical trials than it is diabetes pathway is the incidence of new diabe- in the real world, and thus an intervention's tes cases. The main outcome metric for the early benefits may be lower in actual practice than management stage of CHD is the incidence of trial results suggest. Similarly, an intervention's AMI or unstable angina. Health International 2011 Number 11
Case study:
Northamptonshire NHS grew concerned about rising mentoring the GPs about how diabetes can better be diabetes prevalence in its region, especially given its managed, especially in its early stages. The diabetologist Using a diabetes
existing problems with diabetes care. Many patients also helps the GPs better understand when disease care pathway
were not being offered appropriate early treatment, progression warrants referral to a specialist. to reallocate
and thus the region's rate of diabetic complications was above the English average. Despite its high spending In addition, Northamptonshire increased the capacity on diabetes care, patient satisfaction was low and the of its patient education classes to help people better outcomes achieved were relatively poor. Northamptonshire manage their disease; it also increased its investments therefore decided to review its diabetes pathway to better in mental health and podiatry services to provide better understand how it could reallocate resources to improve support for diabetic patients. In addition, it offered extra the quality of care delivery and the results achieved.
training to practice nurses to improve their ability to administer different forms of insulin and to teach patients The region gathered prominent local clinicians, including how to administer insulin to themselves. diabetologists and general practitioners (GPs), to help it improve the pathway and determine what changes needed Initial results have been strong. In the first seven months to be made. For example, the investigation made it clear alone, Northamptonshire saved £373 thousand in pre- that Northamptonshire was focusing too many of its efforts scription costs, largely because effective generic drugs – and too much of its funding – on the acute-care manage- are being used more widely.1 It is too soon yet to see a ment of diabetic complications. Too little emphasis was drop in the rate of complications (or the resulting need being given to the prevention of those complications. for hospitalization), but Northamptonshire anticipates that within a decade it may save up to £8 million annually, To remedy this problem, Northamptonshire established a through decreased prescription costs and less spending multidisciplinary team of clinicians, led by a diabetologist, on complications. More important, it believes that the to help GPs improve the care they deliver to diabetic and changes it has implemented will significantly improve 1 Unpublished data obtained pre-diabetic patients. The diabetologist spends one day the quality of diabetes care it delivers and the health from NHS Northamptonshire. October 2010.
per week in GP practices, reviewing patients' files and of its diabetic patients.
Supporting the outcome metrics are what we call may not be sufficient to determine whether the process metrics — indicators of whether the right right drug(s) have been prescribed but usually tests and treatments are being used in the appro- will reveal whether the appropriate evaluations priate patients (Exhibit 2). Together, the outcome have been conducted. Those checks can be used and process metrics gauge overall health system as process metrics for diabetes management.
performance. When these metrics are selected, it is important to focus on information that can be Once the relevant outcome and process metrics derived from routinely collected data. For example, have been determined, the health system should diabetic patients are given drug therapy to con- assess its performance on each one. In addition, trol their blood glucose levels, as well as regular it should identify whether there are any other evaluations for foot ulcers, vision problems, and factors driving the outcomes achieved so that it other signs of disease progression. Routine data can determine where it will be best able to have Using care pathways to improve health systems impact. For example, a health system has little begins the process of determining which inter- control over ambient air pollution levels, ventions should be prioritized.
a significant risk factor for asthma exacer- ba tions. However, it can and should ensure Determining optimal service delivery that its asthma patients are given drug therapy Once the fact base has been assembled, the so that their risk of an asthma attack is mini- health system can evaluate its performance mized. By identifying the factors driving out- in each stage and on each step. In some areas, comes that it can modify, the health system the system may find that it is already following A cost waterfall based on a care pathway helps clarify
where money is being spent
Acute care
Percentage of total CHD spending
AMI, acute myocardial infarction; CHD, coronary heart disease.
Shown here is a cost waterfall depicting one health system's spending on its CHD pathway. The numbers in each of the bars represent the percentage of total CHD spending allocated to each step or stage in the pathway (the light-colored bars represent steps; the dark-colored bars are stages). This system's total spending on its CHD pathway was roughly equivalent (in purchasing-power parity) to US $84 per person. Of this total, about $37 was allocated to primary prevention; $27, to early management; $12, to acute care; and $8, to rehabilitation and secondary prevention. This level of granular detail enabled the health system to determine whether some of its spending should be reallocated. Health International 2011 Number 11
Case study:
Last year, four members of McKinsey's Health Systems By comparing their performance, the health systems Institute decided to join forces to investigate how well learned that their per-patient spending on common Using a CHD
they were delivering CHD care and how they could im- CHD drugs (e.g., statins and antihypertensives) differed care pathway
prove in the future. They also wanted to learn from each markedly, often in ways that bore little correlation with to compare
other. Analyzing their CHD pathways helped them better outcomes. They also discovered that spending levels health systems'
understand what services they were delivering, what in other areas did not always correlate with results it was costing them to deliver those services, what out- comes they were achieving, and how their performance compared.
For example, the health system with the highest spend- ing on acute care had the lowest inpatient survival rate The four members − all regional health systems in following AMI (exhibit). On further analysis, it discovered developed countries − had set themselves a daunting that it had the lowest proportion of eligible patients task. Many of the metrics they decided to analyze receiving primary percutaneous coronary inter vention (e.g., the percentage of acute myocardial infarction (PCI), even though it devoted considerably more of its CHD [AMI] patients assessed for cardiac rehabilitation) were spending to that procedure than any other system did. not ones they routinely collected, and thus they had to find novel ways to dig the information out of their IT Each of the health systems is using the findings in systems. In addition, they had to develop a method for different ways to redesign CHD care delivery. For ex- making each member's data set comparable with the ample, the system with the lowest PCI rate has decided others. However, the insights they gained made the to focus first on improving access to that procedure. effort worthwhile.
Two other systems are concentrating on increasing their rehabilitation and secondary prevention efforts; they All four health systems now have a much clearer idea plan to support each other as they redesign services of what services should be delivered at all stages of the and then to compare the results they achieve. All of the pathway and what outcomes should be achieved. They systems are using the CHD pathway to better understand also have a clearer idea of what they are spending at variations in care delivery and outcomes achieved within each stage. All four systems were surprised to realize, their own regions.
for example, how little they were spending on secondary prevention and rehabilitation in comparison with primary or acute care.
" All four health systems now have a much clearer idea of what services should be delivered at all stages of the pathway and what outcomes should be achieved. They also have a clearer idea of what they are spending at each stage." Using care pathways to improve health systems Spending differences do not always predict outcome differences
Acute care
Percentage of total CHD spending
• Proportion of total CHD funding spent on acute care: 14% • In-hospital mortality rate: 3.7% Acute care
Percentage of total CHD spending
• Proportion of total CHD funding spent on acute care: 30% • In-hospital mortality Region B's proportional spending on
acute care is twice that of region A,
but its in-hospital mortality rate is
three times as high.
AMI, acute myocardial infarction; CHD, coronary heart disease.

Health International 2011 Number 11
we have seen health systems looking to improve performance create detailed lists of all the things they need to fix but then have no way to prioritize the necessary changes. A care pathway helps them avoid this risk because it allows them to make sound comparisons based on clinical evidence and financial insights. Similarly, the clinical evidence base and finan-cial data behind the pathway can help health systems determine when it may be appropriate to reconfigure services to achieve the goals they have set for themselves. In our experience, care pathways often reveal gaps in service delivery, especially during the hand-offs from one pro-vider to another. A health system can use these insights to reconfigure services to minimize these gaps. In addition, a care pathway can help the health system determine whether its spending on each stage of the pathway is appropriate (Exhibit 3). In some cases, a health system may discover that it is over-investing in certain forms of care and can transfer money into other areas (or reduce spending) without adversely affect-ing outcomes. best practices and achieving strong results. Identifying the appropriate enablers In other areas, it may find that its outcomes are In our experience, the health systems that have suboptimal. It must then begin to consider — derived the greatest benefit from care pathways based on the significance of the performance share several traits. These traits can be consid- deficits and the cost of correcting those deficits ered enablers of success.
— which areas to focus on first. First, clinicians must lead the pathway's The care pathway provides additional help in devel opment and implementation. Clinicians this regard because it enables the system to are in the best position to evaluate the clinical objectively compare interventions to determine evidence, and their involvement builds support which ones have the greatest impact and which for the changes to care delivery. (In our experi- deliver the highest value. In this way, the system ence, the absence of clinician involvement has can develop insights into how it can best over- derailed otherwise well-designed improvement come its performance deficits. All too often, projects.) The clinicians chosen to lead the Using care pathways to improve health systems " Optimal use of a care pathway requires general practitioners, specialists, and other health professionals to work closely together (even if one clinician serves as the primary contact for each patient)." project should be given capability- building Fifth, the health system must put in place an training to improve their leadership skills. effective governance structure to make certain The health system may also find it useful that there is clear, pathway-wide accountability to provide training for the other clinicians for outcomes and costs. Optimal use of a care affected by the changes to increase their pathway requires general practitioners, spe- buy-in for the project.
cialists, and other health professionals to work closely together (even if one clinician serves Second, patients must be given information as the primary contact for each patient). With- and education to ensure that they take appro- out an effective governance structure, it can be priate advantage of the services the health difficult to maintain accountability as patients system delivers. Education is especially impor- are transferred from provider to provider.
tant for chronic disease care pathways, such as those for CHD and diabetes, because it strongly influences whether patients are willing to adopt Today's economic environment makes it im - healthier behaviors, comply with treatment, portant that health systems produce the best and engage in other forms of self-care.
possible outcomes while keeping costs under control. Care pathways can help them do that Third, the health system must invest in tech- by enabling them to make evidence-based nology and information systems to help ease the decisions about where to focus their improve- flow of data among providers. For example, the ment efforts. • system should find ways to make it easier for clinicians to access patient records through Olivia Cavlan, MD, an associate in McKinsey's
London office, has worked with several health systems
registries and other tools.
to implement care pathways. Penny Dash, MD,
a prin cipal in that office, leads the Firm's work on
Fourth, the health system must ensure that re designing health systems to improve patient it has sustained funding for both development outcomes, increase efficiency, and reduce costs. and imple mentation of the pathway. In addition, Jean Drouin, MD, a principal in that office and head
it must con sider whether incentives (e.g., pay- of the McKinsey Health Systems Institute, focuses on how health systems can improve the value of the care for-performance bonuses given to doctors or they deliver. Tim Fountaine, MD, PhD, an associate
their practices) should be included in any service prin cipal in the Sydney office, specializes in strategy redesign to further encourage clinician support and health systems work. Farhad Riahi, MD, is an
for the necessary changes. alumnus of the Firm.


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LA ASAMBLEA NACIONAL DE LA REPÚBLICA BOLIVARIANA DE VENEZUELA la siguiente, LEY DE AERONÁUTICA CIVIL TÍTULO I DISPOSICIONES GENERALES Artículo 1. La presente Ley regula el conjunto de actividades relativas al transporte aéreo, la navegación aérea y otras vinculadas con el empleo de aeronaves civiles donde ejerza su