Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis using Radiological Criteria

Author(s):

Gabriel Gonzalez; Esteban Montemayor; James Sanders; Mandy Burton; Jeffrey Tessier; Therese Duane

Background:

Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multifaceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis.

Hypothesis:

Provider compliance will vary based on decision points across a standardized clinical pathway.

Methods:

An institutional wide clinical pathway was developed to manage diverticulitis, including radiological classification, primary service line assignment, interventional strategies and antibiotic treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients treated from June 1, 2016 to February 9, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiological documentation (modified Neff [mNeff] classification), primary service assignment and interventions (i.e., interventional radiology [IR] and antibiotics).

Results:

The cohort represented a diverse group of mNeff classifications with the following distribution: Stage 0 (43.4%), Stage 1 (18.1%), Stage 1a (13.3%), Stage 1b (7.2%), Stage 2 (7.2%), Stage 3 (0%), Stage 4 (1.2%), Undefined (9.6%). Of the patients included, 27.7% had a previous history of diverticulitis and 24.1% had recurrent diverticulitis. Patients received a total duration of antibiotic therapy (mean ± SD) of 10.2 ± 5.1 days. Table 1 demonstrates compliance with the clinical pathway.

Table 1

Compliance category	% (n/N)
Overall	9.6 (8/83)
mNeff documentation	90.4 (75/83)
Primary service assignment
Non-surgical primary team mNeff 0	100 (36/36)
Non-surgical primary team mNeff 1 or 1a	88.4 (23/26)
Surgical primary team mNeff 1b	16.7 (1/6)
Surgical primary team mNeff 2-4	100 (7/7)
IR drainage for mNeff 1b	16.7 (1/6)
Antibiotic choice	20.5 (17/83)
Antibiotic duration	69.9 (58/83)
No source control	74.3 (55/74)
Source control	33.3 (3/9)

Conclusions:

Overall compliance with the clinical pathway was poor; except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line and antibiotic duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.