New Clinical Pathways Definition Developed to Help Guide Future Research

Using the foundation of past studies, researchers have described the process for developing, refining, and pilot testing a set of criteria for a practical operational definition of clinical pathways in health care. 

Pathways, standardized methods of care incorporating the best, evidence-based methods, are increasingly being implemented at health care institutions and systems. Many of these institutions also use quality improvement concepts to ensure that pathways are being continuously updated and always using the best evidence base. However, a lack of conceptualization and differences in definition have resulted in considerable confusion in the field of pathway research.  

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A paper published in BMC Medicine and led by Adegboyega K Lawal, BPharm, MPH, PMP, University of Saskatchewan (Saskatoon, Canada), looked to help clarify some of the conversations surrounding clinical pathways by describing the process of refinement and rigorous testing used to obtain an operational definition of pathways in order to better guide future research 

The paper builds on past research conducted by Kinsman et al in which a team developed a set of criteria for the practical operational definition of clinical pathways. That 2010 study set up a list of 5 criteria: (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to channel the translation of guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other “inventory of actions;” (4) the intervention had timeframes or criteria-based progression (ie, steps were taken if designated criteria were met); and (5) the intervention aimed to standardize care for a specific clinical problem, procedure, or episode of health care in a specific population.

If an intervention met the first and any three of the subsequent criteria, it was considered to be a clinical pathway. However, while attempting to perform a systematic review of pathways in primary care, researchers found that it was difficult to apply the criteria to a primary care setting due to the fact that many interventions were unable to satisfy criteria three and four simultaneously. Therefore, authors of the new study merged the two criteria, narrowing the operational definition of clinical pathways to a four criteria checklist. 

Two review authors tested the criteria on 20 articles randomly selected from the 2010 review on clinical pathways, with the goal being that the number of articles retrieved would remain unchanged after using the modified criteria. 

Using the revised criteria generated an 85% (17/20) observed agreement from the two independent reviewers, with further statistical analysis implying perfect agreement. As such, the authors wrote that the new definition would be applied to identify relevant titles and abstracts for an on-going update of reviews on clinical pathways in hospitals and a new review on pathways in primary care. 

Researchers concluded that their research showed an adequate way in which a criteria for the definition of clinical pathways can be developed, refined, and tested. 

“This will lead to a better understanding of how clinical pathways may contribute to better health care,” wrote the authors. 

Future research on the evaluation of clinical pathways should use the developed definition or a modified version to fit that study.—Sean McGuire 


Lawal AK, Rotter T, Kinsman L, et al. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. BMC Medicine. 2016;14:35. doi:10.1186/s12916-016-0580-z.