The Effect of Clinical Pathway Implementation on the Length of Days of Ischemic Stroke Patient Hospitalization at Three Hospitals in Indonesia

Abstract

Clinical pathways (CP) regarding stroke is a medical service standard necessitated ensuring quality health services at rational costs. The previous study showed that the effect of CP implication on hospitalization length has not shown conclusive results in one hospital nor considered the CP format used. Therefore, this study aims to measure the implication of ischemic stroke CP on hospitalization length. This study was conducted in public and private hospitals, type A and B, which run a stroke registry with uniformity in stroke care and CP format. A retrospective cohort design was used to measure the effectiveness of the ischemic stroke clinical pathway on the outcome of hospitalization length by controlling for confounding variables, including demographic factors, comorbidities, clinical, service procedure, and management support. The data source for the Ischemic Stroke CP group was obtained from the document in the hospital. The data of the without CP group was obtained from the Stroke Registry of the Research and Development Agency, and the medical record was traced to obtain the required variables. The population is ischemic stroke patients treated from January 2012-December 2015. The sample was selected purposively, meeting the inclusion and exclusion criteria, and the ischemic stroke diagnosis is based on medical records with ICD-X 163.9. The cut-off point for the length of hospitalization was determined by Receiver Operating Characteristic analysis, divided into 2 categories, long (>8 days) and short (≤8 days). Univariate, bivariate, stratification and multivariate analysis were performed using the Cox regression test. The results showed that 71% of the subjects were treated without CP, 65% had a short hospitalization length (<8 days), 39% were aged 18-55, and 57% were male. In men, 88% had dyslipidemia, 77% were admitted with mild severity as measured by the Glasgow Coma Scale (GCS = 15), and 35% had attack onset of admissions >24 h. The stratification test showed no interaction between the independent (CP) and the covariate variable on hospitalization length. Multivariate analysis found that CP significantly reduced the risk of hospitalization length (>8 days) by 53%, compared to patients treated without CP, after controlling for disease severity,