As managed care's presence has expanded throughout the health care system, hospitals have increasingly looked to clinical pathway protocols as a mechanism to reign in costs for both chronic and acute conditions. The goal of a clinical pathway is to streamline care by defining in advance the optimal sequence of events from the time the patient is admitted to when the patient is discharged. The Rehabilitation Institute of Chicago will be instituting two new clinical pathways for rehabilitation care for stroke and spinal cord injury in 1999. The objective of this study is to examine prospectively clinical rehabilitation pathways for stroke and paraplegic spinal cord injury to determine how the critical economic, patient and provider outcomes change over time. The proposed study will expand the state of knowledge regarding clinical pathways in several dimensions. First, the project will begin to address the critical issue of whether patients are better off in clinical pathways, regardless of any cost savings, by examining patient satisfaction measures and other indicators of quality of care. Second, in addition to examining static outcomes such as cost and length of stay, the study will also focus on the relationship between several outcome measures at the patient and provider levels, and how those relationships change over time. Detailed data will be collected on consecutive patients in the stroke and spinal cord injury programs for eight months prior to and following pathway implementation. Patient satisfaction with care will be assessed one month post-discharge, and provider satisfaction will be assessed both prior to implementation and at monthly intervals following pathway implementation. Multivariate analyses will control for confounding factors including patient characteristics and type and severity of impairment at admission. How patients are selected to be on a pathway will also be examined in order to measure and control for the bias introduced by the non-random selection.
