Published 11/30/2019
Barbara Krause; Nicole Nelson, MPH

Clinical Care Pathways: Incorporating Evidence into Practice

AAOS CPG on osteoarthritis of the hip

Care pathways, or clinical care pathways, are widely used in numerous U.S. healthcare settings. Pathways are characterized as multidisciplinary management tools, based on evidence-based medicine and input from content experts to guide care for a specified patient population with a specific condition.

Realizing that care pathways provide an additional mechanism for integrating evidence-based care into clinical settings, AAOS is developing clinical care pathways that will be based on published AAOS clinical practice guidelines (CPGs). Multiple iterations of each pathway will be developed and published in recognition of the differences in feasibility across care settings. AAOS recently created two iterations of pathways designed for adult patients presenting with varying degrees of hip and/or groin pain. Both pathways are intended for use by orthopaedic surgeons and physicians managing patients with osteoarthritis of the hip (OAH) and were based on the 23 recommendations from the 2017 AAOS Management of Osteoarthritis of the Hip CPG. The guideline included both invasive and noninvasive treatments for OAH and also addressed prognostic factors associated with poorer patient-reported outcomes. To view the guideline, visit www.orthoguidelines.org/topic?id=1021. In addition, diagnostic modalities based on the 2017 AAOS Appropriate Use Criteria for the Management of Osteoarthritis of the Hip were integrated into both pathways.

Utilizing the “moderate evidence” to “high evidence” recommendations from the guideline, key recommendations, such as the use of risk-assessment tools, physical therapy to improve function and decrease pain, nonnarcotic pain management, and intra-articular injectables, were extracted to begin development of the pathways. Modalities such as intra-articular hyaluronic acid injections, glucosamine chondroitin supplements, and opioids were not included, as they lack moderately strong supporting evidence. Common strategies, such as activity modification and assistive devices, were drawn from those provided by the content experts in the OAH appropriate use criteria. For surgical recommendations in the pathway, moderate evidence supports the use of tranexamic acid to reduce risk of blood loss and transfusion, with no preferential difference in outcomes based on surgical approach.

After an initial general care pathway was outlined, hip specialists provided valuable input on its relevance and feasibility based on their individual clinical settings, local resources, and medical protocols. Additional expert opinions filled gaps where limited evidence supported any strong stance on specific pathway steps, such as patient optimization. The content experts
included patient optimization prior to treatment to minimize the risk of adverse events. Both pathways note the need to assess modifiable risk factors, such as obesity, poorly controlled diabetes, mental health issues, substance-abuse disorders, tobacco and opioid use, and malnutrition, when surgeons discuss treatment options with patients. Depending on potential risk factors, preferred treatments may be delayed until factors are addressed adequately.

Of the two iterations of the pathway developed to date, a key differentiation is the timing of radiographic evaluations. This minor modification is associated with the availability of local resources. For instance, in larger institutional settings, such as hospitals or referral settings, X-rays often are ordered prior to an orthopaedic surgeon’s consultation, whereas smaller institutional settings defer radiographs until a patient’s initial evaluation by the specialist.

Not all possible clinical settings are contained in the pathways, and clinical judgement supersedes these maps. For example, on the rare occasion when a patient presents with severe pain and radiographically mild OAH, additional workup for extrinsic causes of pain should be considered. The clinician may need to consider other diagnoses, which extends beyond the scope of either pathway.

Care pathways are not intended for use in benefits determination, as no one care pathway is feasible for all clinical care scenarios, nor is one singular care pathway appropriate for every individual patient. However, recommendations based on strong and moderate evidence can be utilized as a starting point, then clinical expertise can determine additional steps and modifications to ensure that pathways are relevant across different settings and individual patients based on local resources, feasibility of implementation, costs of treatments, and clinical judgment.

Both pathways can be modified based on local resources to create a feasible and appropriate guide for treatment in any clinical setting, and AAOS encourages members to modify these pathways for their own use. Additional iterations of this care pathway can be forwarded to Kaitlyn Sevarino, senior manager of AAOS’ Department of Clinical Quality and Value, at sevarino@aaos.org. Pathways will be reviewed for publication on AAOS’ Clinical Quality and Value website.

Resources for management of OAH, including care pathways, can be located at www.aaos.org/osteoarthritiship in the Clinical Quality and Value section of the AAOS website.

Barbara Krause is the quality-improvement specialist in AAOS’ Department of Clinical Quality and Value.

Nicole Nelson, MPH, is the lead research analyst in AAOS’ Department of Clinical Quality and Value.

Why do we need clinical care pathways?

Pathways offer stepwise sequences easily incorporated into routine clinical care to facilitate shared decision-making at various stages of investigation or intervention. The objective of evidence-based clinical pathways is to assist clinicians in reducing variations in treatment to create more standardized care, improve patients’ clinical outcomes and satisfaction, and increase the efficiency of healthcare resource utilization. Care pathways can also be used to facilitate conversations between clinicians and patients, as they can indicate what a patient may expect.