Critical pathways: design, implementation, and evaluation.

As David M. Eddy, M.D., Ph.D., Senior Advisor for Health Policy and Management to Southern California Kaiser Permanente, discusses in his excellent book, Clinical Decision Making: From Theory to Practice (1), we are now in a time where we must rethink what we are doing and how we are doing it. Substantial variations among physicians in almost every aspect of the diagnostic process have been documented repeatedly, and these variations appear to cause patients to be treated differently. Eddy says these variations are not the fault of physicians or anyone else because of the complexity of the medical decision process. Nonetheless, the cost and quality of health care have suffered as a result. Numerous articles and individuals such as Jay McDonald, M.D., Professor and Chair of the Department of Pathology at the University at the University of Alabama at Birmingham Medical Center, also have highlighted these variables in practice patterns and their consequences (2). Dr. Eddy, Dr. McDonald, Michael G. Bissell, M.D., Ph.D., Director, Clinical Pathology, Allegheny General Hospital, Pittsburgh, Pennsylvania, and other leaders in the field have stressed the need for more standardization of health care; clinical decisions concerning diagnostic testing and therapeutic choices must be based on scientific evidence that demonstrates the practice being used is truly effective (1-6). This evidence, as well as other parameters discussed below, are known as outcomes. As expressed by Dr. McDonald, "there is a transition that is going on from doing what seems best to doing what one knows is best" (2). Practice guidelines and critical pathways now are seen by many as one solution to providing more standardization of health care and to meeting the demands of the rapidly changing medical environment for simultaneously increasing the quality of care while decreasing the costs.