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In Defense of a Beaten Path
Making the case for establishing clinical care pathways.
Illustration by Andre DaLoba
In our Johns Hopkins Health System, there can be considerable differences in the way we treat two patients with the same diagnosis. Often these differences are justified (see Hopkins Medicine’s special issue on precision medicine, Winter 2017). Other times this variation is based not on a patient’s special characteristics or what the data indicates or even a physician’s intuition—but rather our own habits as practitioners.
Scholars of health care have a name for this phenomenon—unwarranted variation—and it is one of the most unrelenting problems in medicine. While estimates vary, unfounded variation in care adds up to as much as $600 billion in avoidable health care spending per year in the United States. Reducing this clinical variation is not just a cost-control measure: It is a necessary step toward better outcomes and more satisfied patients. Knowing that preventable medical errors are a leading cause of death in this country provides tremendous incentive to follow proven protocols in typical cases.
Here’s an example. Anterior cervical discectomy and fusion, or ACDF, is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure causing pain or numbness. In the past, each of the various orthopaedic surgeons and neurosurgeons at our five adult hospitals had their own set of orders governing pre- and postsurgical care.
For instance, some surgeons would have the patient go from recovery to the floor, where nurses would feed patients and get them out of bed right away. Other surgeons would request a swallowing evaluation first. Some patients would be required to wear a neck collar and others would not. The timing of X-rays varied widely. All of that could tack days onto the recovery, depending on who operated. And because the process varied by provider, even within the same hospital, it was challenging for residents and nurses, who had to memorize preferences specific to each surgeon. Moreover, patients would get jumbled signals.
So Jean-Paul Wolinsky, a professor of neurosurgery here, joined with his colleague David Cohen in orthopaedics to see if they could establish a consistent, evidence-based care pathway for ACDF. They involved colleagues from Sibley and Suburban, nursing, occupational therapy, and others who formed a multidisciplinary Spine Clinical Community.
What this team came up with was a single optimal pathway that takes ACDF patients all the way from the beginning of their check-in through their hospital stay and discharge. Then came the hard part: getting others to buy in.
Initially, there was some resistance to change. But physicians are scientists, and they respond to compelling data. Ultimately, the group has been able to persuade surgeons by showing the benefits of streamlining care—including a one- to two-day reduction in average length of stay—and now the pathway is operational across the system with high adoption. With standardization, there are clear expectations and fewer errors. Plus, everyone stays current on best practices.
Currently we have 23 such clinical communities at Johns Hopkins Medicine, focused on quality-improvement projects in areas ranging from diabetes to clinical disinfection.
Of course, in a community of exceptionally gifted and experienced physicians, some will bristle at these efforts, perceiving an attack on their professional autonomy. Far from a crackdown on creativity, however, we expect these projects to have the opposite effect. First, an established care pathway gives us a standard against which to measure new innovations, to determine whether they actually make a difference in outcomes. Second, when we apply these protocols in straightforward cases, it frees up time and mental energy for physicians to operate more autonomously in complex cases and to focus their creativity on big-picture initiatives aimed at improving health care.
Most importantly, there are no administrators in central offices handing down clinical order sets. In fact, some have described this movement as replacing a physician’s autonomy with physicians’ autonomy—a profound distinction achieved by a very subtle shift of the apostrophe. I am confident that when you bring together world-class clinicians to share notes and strategize, their collective wisdom will improve health care in ways we have yet to even imagine.