Methods
Review questions and objectives
1.
The primary question is: What are the effects of oncological care pathways on patient, professional, and health system outcomes within primary and secondary (hospital) care settings?
2.
The secondary review questions are: (1) What are the differences in the implementation of oncological care pathways in primary and secondary (hospital) care? And (2) can we explain how these differences might lead to different outcomes?
For the purpose of this review, we will define usual care as treatment determined at the discretion of the attending healthcare professional. Unless studies specify that the control group utilizes some form of standardized care, we will assume the control group utilizes this definition of usual care.
Criteria for considering studies for this review
We will include all studies that address the questions and objectives of our systematic review. We will include studies which tested the implementation of care pathways in primary and secondary (hospital) care and of intersectional care pathways in all healthcare settings.
Types of studies
We will include all primary, quantitative studies which utilize the following study designs: randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies according to the EPOC study design criteria [
24]. Where available, we will include full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses), cost analyses, and comparative resource utilization studies. We will exclude retrospective cohort studies, prospective cohort studies, cross-sectional studies, and case-control studies.
Definition of care pathways
Because there are many definitions of “care pathways” [
9], we will use the working description which was tested and refined in a previous review by Rotter et al. [
10]:
1.
The intervention was a structured, multidisciplinary plan of care.
2.
The intervention was used to translate guidelines or evidence into local structures.
3.
The intervention detailed steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol, or other “inventory of actions” (i.e., the intervention had time frames or criteria-based progression).
4.
The intervention aimed to standardize care for a population of cancer patients.
An intervention is considered to be a care pathway only if it meets all four criteria. Otherwise, the study will be excluded.
Types of institutions and participants
Participants will include patients, care providers, and healthcare organizations in primary and secondary care. All cancer types will be included. Regarding the care providers, we will consider all health professionals, including general practitioners, doctors, nurses, physiotherapists, pharmacists, occupational therapists, social workers, dietitians, psychologists, psychiatrists, and dentists involved in oncological care pathway utilization. Finally, we will group the included studies into primary and secondary care pathways. Also, we will synthesize and report on the studies according to the context in which they have been implemented (primary or secondary care).
Primary outcomes
Objectively measured patient outcomes include (in-patient) mortality, mortality at the end of follow-up, re-admissions (hospital setting), (in-hospital) complications, hospital admissions, adverse events, discharge destinations, performance status, patient satisfaction, quality of life, and absence from work.
Objectively measured professional outcomes include quality measures appropriate to the specific aim of the care pathway, staff satisfaction, team functioning, guideline adherence, and adherence to evidence-based practice.
Objectively defined systems-level outcomes include length of stay, waiting times, and costs.
Secondary outcomes
Any reported measure of the following implementation strategies and methods will be included. We will use the evidence-informed strategies identified and employed by the Cochrane authors in their systematic review, although Rotter et al. [
12] found that reporting of implementation processes was generally poor. Further, we will extract the reported evidence-based processes for developing and implementing care pathways in primary and secondary care. We will group the reported implementation activities according to whether they used evidence-informed strategies. We will categorize reported strategies into (1) pathway development [
12,
25], (2) implementation planning [
12,
26], (3) pathway education [
12,
25,
27], and (4) feedback and reminder systems [
12,
27,
28].
Potential activities involved in pathway implementation include project groups, clinician involvement, local consensus processes, use of an implementation team, identification of potential barriers to change, identification of evidence-practice gaps, local opinion leaders, educational meetings and outreach, printed educational materials, audit and feedback, and electronic reminder systems.
Search methods
We will search the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE) to identify related systematic reviews. The initial search strategy has been developed for OVID MEDLINE and will be translated for other databases (see Additional file
2). We will apply three methodological filters: randomized controlled trials, EPOC designs (controlled before-after studies, interrupted time series studies, and quasi-experimental designs), and economic studies to identify cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses. Search strategies will use controlled vocabulary such as Medical Subject Headings (MeSH) and EMTREE (Embase), and keyword phrases. All databases will be searched from the date of inception forward with neither date nor language limits.
The databases searched are the following:
-
Cochrane Central Register of Controlled Trials, Cochrane Library (Wiley)
-
DARE, NHS Economic Evaluation Database (EED), Health Technology Assessment Database (HTA) (Wiley)
-
MEDLINE, Epub Ahead of Print; In-Process & Other Non-Indexed; MEDLINE R; MEDLINE R Daily (OVID) 1946 to present
-
Embase (OVID) 1947 to present
-
CINAHL (EBSCO) 1981 to present
-
-
-
The American Economic Association’s database for economic literature, EconLit (EBSCO) 1969 to present
Searching other resources
Gray literature
We will search a selection of gray literature sources to identify citations not indexed in the standard bibliographic databases above. Sites will include, but not be limited to, the following:
-
-
-
-
Organizational web sites and professional organizations related to clinical pathways and implementation.
We will also:
-
Screen the following individual journals (e.g., hand search):
-
◦ International Journal of Care Pathways
-
◦ International Journal of Integrated Care
-
Review reference lists of all included studies, relevant systematic reviews/primary studies
-
Contact authors of relevant studies/reviews to clarify reported published information and/or to seek unpublished results/data
-
Contact researchers with expertise relevant to the review topic/ EPOC interventions.
-
Conduct a cited reference search on those studies included in our review in Web of Science
-
Contact the corresponding author to request full text in case of the full text is missing.
Two reviewers will independently screen all titles and abstracts, using Covidence (
www.covidence.org). A third reviewer will be consulted in case of disagreement between the two reviewers. We will further examine potentially relevant studies, using full-text copies.
Two review authors will independently extract data, directly from included studies. Where necessary, we will request additional information from the authors of primary studies. When we include systematic reviews in the analysis, we will assess the methodological quality of these reviews using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool [
29].
When data are missing, we will not impute any values.
Areas of data extraction will include:
-
Study characteristics: publication year, country, length of follow-up period, urban vs. rural location, and inclusion criteria
-
Population characteristics (of patients): age, gender, number of patients, and type of cancer
-
Population characteristics (of professionals): types of healthcare professionals, number of health professionals involved in development, and healthcare setting
-
Intervention characteristics: evidence-based development and implementation strategy(ies) reported.
-
Outcomes: patient, professional, and systems (means, averages, and other uncertainty measures)
Risk of bias assessment
For randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies, we will use the validated criteria suggested by the Cochrane EPOC group to assess the risk of bias in studies with control groups [
24].
The review team will identify criteria for assessing randomized trials, non-randomized trials, and controlled before-after studies: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, similarity of baseline measures, similarity of baseline characteristics, management of incomplete outcome data, selective outcome reporting, and other risks of bias.
The review team will also identify criteria assessing interrupted time series studies: intervention independent of other changes, shape of effect pre-specified, intervention unlikely to affect data collection, blinding of outcome assessment, management of incomplete data, selective outcome reporting, and other risks of bias.
We will summarize the results of the risk of bias assessment across studies and present them in a tabular format.
Data analysis
We will undertake meta-analyses if we find more than two comparable studies which report similar outcomes, within similar contexts, and without statistical heterogeneity. To perform a meta-analysis, we will use RevMan [
30] for calculating a pooled effect (if the clinical and statistical homogeneity across groups of studies is sufficient), using both fixed and random effect models to assess the robustness of the results [
31].
Data synthesis
We will report details on the number of retrieved references, obtained full-text papers, and the included and excluded articles. We will present results of meta-analyses using forest plots. We will adjust cost data for inflation and present these data in US dollars for a common price year.
Assessment of heterogeneity
We will assess heterogeneity within the review and analyze the comparability of the results from individual studies (
I2 = [(
Q df)/
Q] × 100%). The cutoff for substantial statistical heterogeneity will be an
I2 greater than 50%. In addition to considering the quantitative measure of
I2, we will perform the Cochran’s
Q statistical test for heterogeneity [
32].
Assessment of reporting biases
In cases where we find more than 10 studies, we will assess potential reporting biases by visual inspection of counter-enhanced funnel plots [
33,
34]. To test for funnel plot asymmetry, we will use the test proposed by Egger [
35] or the modified version of the Egger test proposed by Harbord in case of small study effects in meta-analyses of controlled trials with binary endpoints [
36].
Subgroup analysis
We will perform a subgroup analysis of the reported primary and secondary outcomes.
We will group studies according to the following categories:
-
Country(ies) where the study was carried out
-
Setting(s) where the implementation of care pathways occurred
-
Year of publication, to assess differences in outcomes reported over time
-
Quality of studies: high versus low risk of bias
-
Age of population: studies including children versus adults
-
Cancer type for which the care pathway was developed and implemented
In our subgroup analyses, we will be using the quantity I2 for estimating heterogeneity, based on Cochran’s Q test, and both statistics will be provided in our forest plots to depict the pooled estimates.
Sensitivity analysis
We will use sensitivity analyses to explore the robustness of the results by investigating the effects of including and excluding studies with high and unclear risks of bias from the analysis.
Ongoing studies
We will describe identified ongoing studies, where available, detailing the primary author, research question(s), methods, and outcome measures. In addition, we will contact the authors of ongoing studies to request raw data for inclusion in our review.
Discussion
The systematic review outlined in this protocol aims to identify, assess, and synthesize all quantitative studies on the effects of care pathways for oncological care meeting the EPOC study design criteria. As a result, the review will provide an evidence base for cancer care pathways regarding patient effects, cost-effectiveness, and implications for implementation. Disseminating the results of the systematic review will be done by publishing the systematic review in a peer-reviewed journal and presenting the results at relevant symposia.
The methodological quality of our systematic review will be reported by using the AMSTAR tool [
29].