Measuring quality and cost of care: evaluation of an amputation clinical pathway.

This study was based on nursing literature supporting the use of clinical pathways in case management systems to improve quality, reduce cost, and increase efficiency. Its purpose was to provide a descriptive analysis of outcomes in lower-extremity amputation caused by arterial occlusive disease. Patients were admitted between Jan. 1, 1989, and Sept. 1, 1995, with arterial occlusive disease for an above- or below-knee amputation and were cared for in three consecutive phases of nursing case management: (1) without a clinical pathway (group I), (2) with a consultation to rehabilitation services in the postoperative stay (group II), and (3) with a rehabilitation-focused clinical pathway (group III). The results of the study indicated more patients were able to return home from acute care and rehabilitation (52%) in group III than in group I and group II (40% and 44%, respectively). In addition, the hospital length of stay was reduced from 11 days to 8 days (geometric mean) once a rehabilitation consultation was included in the plan of care (group II). Although hospital charges rose initially with rehabilitation consultation ($18,627), they were reduced significantly when the pathway was used ($12,629; adjusted for rate increases). When patients were separated by level of amputation, those with below-knee amputations in group III had a significantly shorter length of stay and lower hospital charges than those in the other two groups, but comorbidity remained high. Nurse case managers can use this clinical pathway as a model for care as the findings support its cost effectiveness. They also demonstrate its effectiveness in enhancing the of quality care through a rehabilitation-focused, goal-oriented plan to return patients home.