Showing the pathway forward

When it comes to building pathways out of healthcare event data, it’s crucial not to be put off by the apparent scale of the task. In fact, it's important to realise that a great deal can be done even with relatively limited data. Equally, we have to bear in mind that a key to achieving success is making sure that the results are well presented, so that users can understand them and get real benefit from them. 

Since that means good reporting, and therefore a breach with the practice I described in my last piece, this post is going to be rich in illustrations. They were most kindly supplied by Ardentia Ltd (and in the interests of transparency, let me say that I worked at the company myself for four years). The examples I've included are details of screenshots from Ardentia's Pathway Analytics application, based on sample data from a real hospital. At the time, the hospital wasn't yet in a position to link in departmental data, for areas such as laboratory, radiology and pharmacy, so the examples are based on Patient Administration System (PAS) data only. My point is that even working with so apparently little can provide some strikingly useful results.  

The screenshots are concerned with Caesarean sections for women aged 19 or over. The hospital has defined a protocol specifying that cases should be managed through an ante-partum examination during an outpatient visit, followed by a single inpatient stay. Drawing on Map of Medicine guidelines, it suggests that a Caesarean should only be carried out for patients who have one of the following conditions: 

• Gestational diabetes
• Complications from high blood pressure
• An exceptionally large baby
• Baby in breech presentation
• Placenta praevia

The protocol can be shown diagrammatically as two linked boxes with details of the associated conditions or procedures. For example, the second box in the diagram shows the single live birth associated with the section, and then five conditions one of which should be present to justify the procedure. 

Detail of an Ardentia Pathway Analytics screen with a protocol for Caesarean Sections

Next we compare real pathways to the protocol. At top level, we look only at the PAS events (OPA is an outpatient attendance and APC is an inpatient stay):

Part of the screen comparing actual pathways to the protocol (the full screen contains several more lines).
Note the low-lighted line, second from the top, that corresponds to the protocol shape.

The first striking feature of the comparison is that only a minority (14%) of the cases corresponds to the protocol at all. 65% of the cases have a single admitted patient care event without an outpatient attendance. This should lead to a discussion of whether the protocol is appropriate and whether this kind of case could be legitimately handled with a single inpatient stay and no prior outpatient attendance (perhaps as a an alternative protocol structure).

Another feature is the number of cases involving a second or subsequent inpatient stay. Now there’s a health warning to be issued here: these screens are from a prototype product and the analysis is based on episodes, not spells, so we can’t be certain the second admitted patient care event is an actual second stay – it might be a second episode in the same stay. If, however, an enhanced version of the product showed there really were subsequent stays, we’d have to ask whether what we are seeing here are readmissions. In which case, is something failing during the first stay?

We can drill further into the information behind these first views. For instance, we could look more closely at the eight cases which apparently involved an outpatient attendance followed by two inpatient stays:

Three pathway shapes or types followed by cases that apparently
involved an additional inpatient stay

 The first two lines show instances where the delivery took place in the first inpatient stay (the box for the first stay is associated with a circile containing the value '1', corresponding to the entry in the protocol for a single live birth). In seven of these cases, the patient needed further inpatient treatment after the Caesarean. The last line shows something rather different: the patient was admitted but not delivered and then apparently had to be brought back in for the delivery.

Note that the middle line shows that just two cases out of the total of eight are associated with a diagnosis specified by the protocol as a justification for a Caesarean: they are linked with condition 5, breech presentation. The fact that no such information is recorded for the other six suggests either that Caesarean sections have been carried out for cases not justified by the protocol, or that key data is not being recorded. Either way, further investigation seems necessary.

We can also look in more detail still at individual cases.

Clinical details for a specific event

The example shows a case that has followed the protocol: an ante-partum examination was carried out on 5 May and the patient was admitted on the same day, with the Caesarean section taking place on 8 May. The ticked box in the greyed-out diagram shows that a condition justifying the caesarean has been recorded (placenta praevia). This is confirmed by the highlighted box of detailed information (note that the consultant's code has been removed for confidentiality reasons).



The simple examples here show that pathway analysis provides a real narrative of what happens during the delivery of healthcare to a patient. On the one hand, it can answer certain questions, such as why a Caesarean was carried out at all, and on the other it can suggest further questions that need investigation: what went wrong with this case? why was the procedure carried out in the first place? was there a significant deviation from the protocol?



If we can do that much with nothing more than simple PAS data, imagine how powerful we could make this kind of analysis if we included information from other sources too...