Impact of care pathways on the care of people with diabetes mellitus
This thesis aimed to develop care pathways for the management of in-patients
and outpatients with diabetes in an acute NHS Trust, to review the evidence-base
for existing care pathways and to evaluate the impact of care pathways on the
management of in-patients with diabetes and patients with Diabetic Nephropathy.
A comprehensive literature review (using the principles of a systematic review)
was completed to determine whether care pathways improved the management
and or outcome of hospital in-patients with a medical or surgical condition.
From this review it appears that the main potential benefits associated with the
introduction of a care pathway are a reduction in length of stay, reduced costs
and possible improvements in the quality of patient care. However, these
findings are limited because of the poor methodology used in all of the papers
reviewed and there is a need for more robust research concerning care pathways.
This work has provided a systematic process for developing diabetes care
pathways and examples of diabetes care pathways that could be used and adapted
by other clinicians managing patients with diabetes.
A randomised controlled trial examined the impact of the in-patient diabetes care
pathway on HbA1c, length of stay, re-admissions within 12 months, nurse
knowledge and the quality of in-patient care. In terms of the primary endpoint of
HbA 1c, the null hypothesis cannot be rejected as there was no difference
between the study groups. In the main, secondary endpoints improved, but
limitations in the design and execution of the study preclude excessive weight
being attached to these findings. Furthermore, completion of the care pathway
was poor and sustaining its ongoing use outside of a research study may be
difficult, further work is needed to assess the cost of wider implementation of
this care pathway.
A care pathway-driven Diabetic Nephropathy service was developed,
implemented and evaluated to examine whether it resulted in improvements in the management of Diabetic Kidney Disease (DKD). The results demonstrated
successful implementation of six key evidence-based interventions for DKD and
more importantly both surrogate and hard endpoints were comparable to those
achieved in recent large clinical trials, in particular, the rate of doubling of serum
creatinine, progression to End Stage Renal Failure and Death.
This thesis demonstrates that in some circumstances care pathways can improve
implementation of evidence-based diabetes care and lead to improvements in
patient outcomes. Care pathways appear to be particularly useful when used by a
dedicated, appropriately trained team dealing primarily with one condition, and
can be an effective tool for the implementation of evidence-based diabetes care.
Further work examining the impact of care pathways in all areas of health care
would be useful.