|Year : 2014 | Volume
| Issue : 1 | Page : 180-186
Effects of clinical pathways used in surgery for uterine fibroids: A meta-analysis
Song Xuping1, Tian Jinhui2, Cui Qi1, Ding Guowu3, Yang Kehu2, Zhang Peizhen4
1 School of Public Health; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
2 Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
3 School of Public Health, Lanzhou University, Lanzhou 730000, China
4 Women and Children Hospital of Lanzhou City, Lanzhou 730000, China
|Date of Web Publication||23-Apr-2014|
No.74 Wu Quan West Road, Chengguan District, Lanzhou-730 000, Gansu
Source of Support: None, Conflict of Interest: None
Background: Whether clinical pathways (CPWs) used in surgery for uterine fibroids have positive effects or not remains unclear.
Aims: To assess the implementation effectsof CPW sin surgery for uterine fibroids.
Materials and Methods: Eight databases were searched comprehensively from inception to November 2012, which including the Cochrane Library, PubMed, EMBASE, Web of Science, Chinese Biomedical Literature Database, etc. Two reviewers selected studies, assessed risk of bias, and extracted data of included studies independently. Jadad methodological approach was applied to assess the quality of included studies and meta-analysis was conducted by RevMan 5.1 software.
Results: Ten studies involving 775 patients were included. The aggregate overall results showed that a shorter average length of stay (mean difference (MD) = -1.61; 95% CI (-1.91, -1.31); P < 0.00001) and days of waiting for surgery (MD = -0.75; 95% CI (-1.06, -0.44); P < 0.00001) were associated with CPWs. A reduction in inpatient expenditures was observed in CPWs compared with usual care (MD = -1197.69; 95% CI (-1582.04, -813.35); P < 0.00001). A higher score of patient satisfaction was also found in CPWs.
Conclusion: CPWs could significantly improve the quality of care in patients undergoing uterine fibroids surgery, which were associated with a significant reduction in average length of stay and days of waiting for surgery, a decrease in inpatient expenditures and an improvement in patient satisfaction. Formulating evidence based CPWs and variation control in CPWs should be focused in the future.
结果：10项研究涉及775例病例。总的总体结果表明，缩短平均住院天数（平均差异（MD）= -1.61；95%可信区间（-1.91~-1.31）；P＜0.00001）和等待手术的日子（MD = -0.75；95% CI（-1.06~-0.44）；P＜0.00001）与临床路径相关。住院费用与常规护理相比减少（MD =-1197.69；95%可信区间（-1582.04~-813.35）；P＜0.00001）。病人满意度得分在临床路径中也较高。
Keywords: Clinical pathways, meta-analysis, surgery, uterine fibroids
|How to cite this article:|
Xuping S, Jinhui T, Qi C, Guowu D, Kehu Y, Peizhen Z. Effects of clinical pathways used in surgery for uterine fibroids: A meta-analysis. J Can Res Ther 2014;10:180-6
|How to cite this URL:|
Xuping S, Jinhui T, Qi C, Guowu D, Kehu Y, Peizhen Z. Effects of clinical pathways used in surgery for uterine fibroids: A meta-analysis. J Can Res Ther [serial online] 2014 [cited 2019 Sep 17];10:180-6. Available from: http://www.cancerjournal.net/text.asp?2014/10/1/180/131460
| > Introduction|| |
Uterine fibroids, also called as leiomyomas or myomas, are benign reproductive tumor arising from the smooth muscle cells. Uterine fibroids are the leading indication for hysterectomy.  Uterine fibroids can cause significant symptoms including prolonged or heavy menstrual bleeding, pelvic pressure or pain, even reproductive dysfunction in rare cases.  The prevalence of uterine fibroids is relatively high. Seventy-seven women suffered from it in their reproductive age  and approximately 25% are clinically apparent tumors.  In addition, the disease burden of uterine fibroids is great. It was estimated that $5.9-34.4 billion cost annually in the United States alone.  Therefore, uterine fibroids are one of severe health problems for female.
Choosing the proper treatment for patients with uterine fibroids is decided by multiple factors. Any treatment do not require for asymptomatic uterine fibroids.  Other treatment options vary depending on the presenting symptoms, location and size of the fibroids, the age and reproductive desires of the patient, and the skill of surgeon.  Generally accepted treatments for uterine fibroids includemedical treatments, conservative treatments of myolysis, selective artery occlusion, and surgical treatment.  Surgical therapy has played an important role in treating uterine fibroids for a long time and has a relatively high level of satisfaction.  Widely accepted surgical therapies by the publicare hysterectomy andmyomectomy, which are also the conventional treatment for symptomatic and rapidly growing myomas. , Therefore, it is representative to regard patients undergoinguterine fibroidssurgery as participants.
Clinical pathways (CPWs) were originated in the United States in the 1980s.CPWs were developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care.  CPWs were designed to minimize delays, resource utilization and maximize quality of care and identified by continuous quality improvement.  With the development of medicine, increasing number of people accepted CPWs. It was reported that 80% hospitals had been applied CPWs in the United States by 2003 and Joint Commission International (JCI) has regarded CPWs as an important criteria for hospital accreditation standards. 
However, CPWs were hindered in the process of promotion due to some ambiguous statements, such as 'cook-book medicine', bothersome, and negating critical thinking.  Therefore, it is urgentto have a meta-analysis to evaluate the implementation effects of CPWs in surgery for uterine fibroids.
| > Materials and Methods|| |
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used to conduct data extraction.
Types of studies
All randomized controlled trials (RCTs) with parallel group design comparing CPWs with usual care insurgery for uterine fibroids.
Type of participants
- Patients with the first diagnosis as uterine fibroids (International Classification of Diseases (ICD) 10: D25).
- Patients undergoing surgical treatments coded below: (ICD9CM-3: 68.29/68.39/68.49/68.41/38.80/39.79/99.29). 
- Myoma have malignant change.
- Patients with previous or coexisting cancer.
- Patients with severe underlying disease, such as serious circulatory or respiratory disorders, renal or liver dysfunction.
Search methods for identification of studies
A comprehensive literature searching was conducted in the following databases: The Cochrane Library (Issue 11, 2012), PubMed (1966-11/2012), EMBASE (1974-11/2012), Web of Science (1974-11/2012), Chinese Biomedical Literature Database (1978-11/2012), Chinese Science and Technology Journal (1989-11/2012), Chinese National Knowledge Infrastructure (1994-11/2012), and Wanfang Database (1998-11/2012). We searched the electronic databases combining medical subject headings (MeSH) terms with free text terms. Search strategy was translated into appropriate vocabularies in different databases. MeSH terms were performed based on the following search string: Critical Pathways, Leiomyoma, and Myoma. Details of search strategy in PubMed were showed in [Table 1]. The languages were not restricted during the document retrieval. In addition, the reference lists of the included articles were also searched, and these relevant studies were checked manually to identify other literature related to our article topics. In order to avoid missing articles, we conducted both online and manual retrieval.
Data collection and analysis
Selection of studies
Two reviewers (Song XP and Cui Q) independently screened all titles and abstracts to assess whether studies met criteria. The studies which cannot be determined by titles and abstracts were subjected to full-text screening. If any controversy was found during the process, we had planned to discuss with each other and overseen by a third reviewer (Tian JH).
Data extraction and management
Extracting data from the included studies were performed by two reviewers (Song XP and Cui Q) independently. Disagreement was resolved by a third reviewer (Tian JH). We contacted with the authors of the primary studies when additional information were needed. The following data were extracted from included studies: First author, year of publication, the average age of the participants, sample size, operative approach, operative path, and reported indicators.
Assessment of risk of bias in included studies
The risk of bias in included studies was independently assessed by two reviewers (Song XP and Cui Q). The modified Jadad 7-point scale was used to assess the risk of bias of included studies. This scale was derived from Jadad 5-point scale,  adding the item of allocation concealment.  The scale address five specific aspects: Randomization generation (0-2 points), blinding (0-2 points), description of withdrawals and dropouts (0-1 point), and allocation concealment (0-2 points). Thus, a total score of 4 or more points is high quality study. Any disagreements were resolved by consensus and the third reviewer (Tian JH) acted as an arbiter.
Statistical analysis was performed by Review Manager 5.1 software which was provided by the Cochrane Collaboration. The mean difference (MD) was recommended for continuous data when all studies use the same scale to report their outcomes, while standardized mean difference (SMD) was more appropriate for studies using different scales. Odds ratio (OR) with 95% confidence intervals (CI) was reported for dichotomous data. Heterogeneity between trials was assessed by the Chi-square test and the extent of inconsistency was evaluated by the I 2 statistic. Meta-analysis was performed using a fixed effects model (P > 0.1) or a randomized effects model (P ≤ 0.1) according to the degree of heterogeneity.
| > Results|| |
Ten RCTs ,,,,,,,,, involving 775 participants met our criteria and were eligible for meta-analysis. Details of selection process from the initial results of publication searches to the final inclusion were shown in [Figure 1]. No statistical difference existed between CPWs and usual care on baseline data of patient characteristics. The PubMed search strategy was presented in [Table 1], and the characteristics of including studies were described in [Table 2]. The evaluation of risk of bias in included studies was showed in [Table 3].
Average length of stay
All studies ,,,,,,,,, reported average length of stay (ALOS). Aggregate results showed that significant heterogeneity existed in included studies (I 2 = 92%; P < 0.00001). CPWs was associated with significant shorter average length of stay (MD = −1.61; 95% CI (−1.91, −1.31); P < 0.00001) [Figure 2].
|Figure 2: Forest plot of meta-analysis: average length of stay (ALOS), mean difference (MD) with 95% confidence interval (CI)|
Click here to view
Inpatient expenditures were reported by all studies. ,,,,,,,,, There was significant heterogeneity inincluded studies (I 2 = 98%; P < 0.00001). CPWs was superior to usual care on inpatient expenditures (MD = −1197.69; 95% CI (−1,582.04, -813.35); P < 0.00001) [Figure 3].
|Figure 3: Forest plot of meta-analysis: Inpatient expenditures, mean difference (MD) with 95% confidence interval (CI)|
Click here to view
Meta-analysis was conducted independently in nine studies, five ,,,, of which reported in percentage and four ,,, reported in mean ± standard deviation (SD). Aggregate overall results of five ,,,, studies reported in percentage showed higher patient satisfaction in CPWs (OR = 5.00; 95% CI (2.25, 11.11);P < 0.0001) [Figure 4]. Additionally, pooled results of four ,,, studies reported in mean ± SD presented that CPWs was superior to usual care on patient satisfaction (SMD = 2.01; 95% CI (1.05, 2.96); P < 0.0001) [Figure 5].
|Figure 4: Forest plot of meta-analysis: patient satisfaction (%), odds ratio (OR) with 95% confidence interval (CI)|
Click here to view
|Figure 5: Forest plot of meta-analysis: patient satisfaction (Mean SD), standardized mean difference (SMD) with 95% confidence interval (CI)|
Click here to view
Days of waiting for surgery
There were three studies ,, reported days of waiting for surgery. Heterogeneityamong three included studies was significant (I 2 = 67%; P = 0.05).The results demonstrated that significant reduction in CPWs compared to usual care (MD = −0.75; 95% CI (−1.06, −0.44); P < 0.00001) [Figure 6].
|Figure 6: Forest plot of meta-analysis: days of waiting for surgery, mean difference (MD) with 95% confidence interval (CI)|
Click here to view
| > Discussion|| |
CPWs have initially been employed in 1980s by United States, which were originally designed to reduce costs for increasing competition in medical care.  CPWs implementation in clinical practices has increased significantly. , CPWs have been applied to a diversity of diseases and they have been promoted in an increasing number of countries. The results of this meta-analysis indicated that CPWs could significantly improve the quality of care in surgery for uterine fibroids. Shorter average length of stay and days of waiting for surgery, reduction in inpatient expenditures, and higher score of patient satisfaction were associated with CPWs. The bias of eight included studies was assessed as low risks. [Table 2] showed the characteristics of including studies, which contained the item of reported indicators. Included studies reported specific indicators differently on postoperative complications (abdominal distension, postoperative bleeding, etc.) and postoperative recovery indicators (ambulation time, anus exhaust time, etc.).
Average length of stay, inpatient expenditures, and days of waiting for surgery
CPWs were superior to usual care in average length of stay, inpatient expenditures, and days of waiting for surgery. Average length of stay and inpatient expenditures were the most commonly employed outcomes, which belong to economic domain. In the meta-analysis, all studies ,,,,,,,,, reported these two indicators. The ALOS and inpatient expenditures were measured as day and RMB, respectively. CPWs regulate subject applicable, diagnosis, selection of treatment options, and preoperative preparations, etc., which also have a timeframe to specify the whole procedure. Positive effects on ALOS, inpatient expenditures, and days of waiting for surgery may be caused by standardization of hospitalization.
As a major indicatorreflecting quality of care, patientsatisfaction was improved significantly in our study. All studies reported patientsatisfaction. Nine studies ,,,,,,,, measured this indicator by a comprehensive scale. While it was collected using a scale which consists of five independent aspects in Cai.  The five aspects are satisfaction on health professionals behaviors, nursing service, hospital management, hospital charges, and quality of care. Thus, meta-analysis was conducted in the nine studies using comprehensive questionnaires. Aggregate overall results of patient satisfaction in percentage and mean ± SD all suggested that CPWs used in surgery for uterine fibroids have positive effects on patient satisfaction.
There are several limitations in this review. Assessment of risk of bias in included studies showed that the majority all studies did not report blinding. However, one reason that cannot be ignored is that blinding was hard to be implemented in surgical operations. In addition, high heterogeneity existed in several pooled results of indicators, which may be caused by following reasons. First, the level of hospitals among included studies was different. Statistics showed that there were six comprehensive hospitals, three moderate level hospitals, and one unclear. The skills and technologies of health professionals may vary in different hospitals. It is accepted by public that LOS is influenced by institution context. Second, it was unclear which inpatient expenditures method was used to generate the data. Moreover, inpatient expenditures were all reported in Mean ± SD. Under the consideration interest rate, the result would be more realistic if inpatient expenditures could be converted into currency in the same year. However, the raw data of majority included studies were not available although we contacted with authors. Third, satisfaction questionnaire used in all included studies were formulated by their specific situation. No authoritative scale was used for reference. Therefore, a random effects analysis was performed to control the heterogeneity and increase the strength of the results.
Future research directions
This review comprehensively summarized and analyzed the RCTs in the field of CPWs implemented in surgery of uterine fibroids. There are some suggestions to recommend. First, establishing evidence based CPWs should be focused in the future. Research on the formulation of CPWs is limited at present. Evidence based medicine seek for current best evidence in making decisions, which could provide a beneficial direction for formulating CPWs. Second, researchers should focus on the control of variation on CPWs. Seeking for the reasons caused variation and finding possible solutions so that more health professionals and patients could enjoy the benefits of CPWs. Third, it would be beneficial to have a series of standard indicator evaluation tools of CPWs. Thus, relatively objective outcomes could be obtained when compared different studies.
| > Conclusion|| |
CPWs could significantly improve the quality of care in patients undergoing uterine fibroids surgery, which was associated with a significant reduction in average length of stay and days of waiting for surgery, a decrease in inpatient expenditures and an improvement in patient satisfaction. As an effective method to improve quality of care, CPWs should be used widely in surgery for uterine fibroids. Formulating evidence based CPWs and variation control should be focused in the future.
| > Acknowledgements|| |
The authors would like to thank Wang Quan, Shi Chunhu, Wang Chenxi, Tian Hongliang, Niu Xiaowei, and Sun Rao for their suggestions to this manuscript.
| > References|| |
|1.||Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007;87:725-36. |
|2.||Stewart EA. Uterine fibroids. Lancet 2001;357:293-8. |
|3.||Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94:435-8. |
|4.||Buttram VC Jr, Reiter RC. Uterine leiomyomata: Etiology, symptomatology, and management. Fertil Steril 1981;36:433-45. |
|5.||Cardozo ER, Clark AD, Banks NK, Henne MB, Stegmann BJ, Segars JH. The estimated annual cost of uterine leiomyomata in the United States. Am J Obstet Gynecol 2012;206:211. e1-9. |
|6.||Hildreth CJ, Lynm C, Class RM. Uterine fibroids. JAMA 2009;301:122. |
|7.||Lefebvre G, Vilos G, Allaire C, Jeffrey J, Arneja J, Birch C, et al. Clinical Practice Gynaecology Committee, Society for Obstetricians and Gynaecologists of Canada. The management of uterine leiomyomas. J Obstet Gynaecol Can 2003;25:396-418. |
|8.||Semm K, Mettler L. Technical progress in pelvic surgery via operative laparoscopy. Am J Obstet Gynecol 1980;138:121-7. |
|9.||Vessey MP, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D. The epidemiology of hysterectomy: Findings in a large cohort study. Br J Obstet Gynaecol 1992;99:402-7. |
|10.||Coffey RJ, Richards JS, Remmert CS, LeRoy SS, Schoville RR, Baldwin PJ. An introduction to critical paths. Qual Manag Health Care 2005;14:46-55. |
|11.||Burns LR, Denton M, Goldfein S, Warrick L, Morenz B, Sales B. The use of continuous quality improvement methods in the development and dissemination of medical practice guidelines. QRB Qual Rev Bull 1992;18:434-9. |
|12.||Deng YH, Wang Z, Ma L, Shi CH, Dong JB. The meaning of executing the clinical pathway and current application situation. Prog Mod Biomed 2010;10:1756-9. |
|13.||Berg AO, Afkins D, Tierney W. Clinical practice guidelines in practice and education. J Gen Intern Med 1997;12:25-33. |
|14.||Xiong H, Li HA. Discuss on the ICD-10 codes of uterine smooth muscle tumor and its operation. Mod Hosp 2012;12:136-8. |
|15.||Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996;17:1-12. |
|16.||Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-12. |
|17.||Tan Y, Lai CS, Wu XF, Pang SF, Qi XM. Evaluation of clinical pathway used in patients with uterine leiomyomas. Clin Med 2011;31:110-2. |
|18.||Cai M. Application study of the clinical pathway in uterine fibroids treatment [dissertation]. Jilin: Jilin University, 2009. |
|19.||Deng LP. Application of clinical pathway in patients underwent uterine leiomyoma surgery. Chin J Gen Pract 2008;6:866-7. |
|20.||Pan R, Bai HM, Chi JQ, Bao SF. Analysis of clinical pathway on hysteromyoma surgical patients. Chin Health Qual Manag 2009;16:22-5. |
|21.||Ren ZT. Study of clinical pathway used in patients undergoing uterine leiomyomas operation of abdominal hysterectory [dissertation]. Xinjiang: Shihezi University, 2011. |
|22.||Yu XJ, Liu W, Tan WH. Implementation of the clinical pathway during hysterectomy. J Nurs Sci 2007;22:36-7. |
|23.||Huang HY. Clinical pathways implemented in patients undergoing uterine leiomyomas laparoscopic surgery. Today Nurse 2011;9:53-6. |
|24.||Zheng DY, Yu Y, Hou JX, Chen J. Application of clinical pathway in uterine leiomyoma patients receiving hysterectomy. Nurs J Chin Peoples Liveration Army 2007;24:12-4. |
|25.||Yu JF. Implementation of clinical pathway in uterine leiomyomas operations. Chin Rural Health Serv Adm 2011;31:1086-7. |
|26.||Jin YM. Effects of clinical pathway used in patients undergoing abdominal hysterectomy. Chin Rural Health Serv Adm 2011;31:744-5. |
|27.||Pearson SD, Goulart-Fisher D, Lee TH. Critical pathways as a strategy for improving care: Problems and potential. Ann Intern Med 1995;123:941-8. |
|28.||Zander K. Integrated care pathways: Eleven international trends. J Integr Care Pathw 2002;6:101-7. |
|29.||Vanhaecht K, Bollmann M, Bower K, Gallagher C, Gardini A, Guezo J, et al. Prevalence and use of clinical pathways in 23 countries-an international survey by the European Pathway Association. J Integr Pathw 2006;10:28-34. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]