Developing the Pathway

What is a care pathway?

Integrated care pathways, clinical pathways, patient journeys and care maps are interchangeable terminology used to describe tools which promote organised and efficient patient care based on the best available evidence and guidelines (Kwan et al., 2004). A care pathway can further be described as a ‘complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period’ (European Pathway Association, 2007). The use of care pathways allows continuous assessment of clinical processes and outcomes against current best practice and guidelines.

Why develop the AARP?

1. There are no high quality, detailed clinical guidelines for aphasia

In order to evaluate the clinical guidelines available for stroke and aphasia, a systematic search of the literature was conducted from February to April 2012 using search strategies modelled on the processes recommended by the ADAPTE Collaboration (2009) (see Rohde et al., 2012  for full details of this process).

It was found that:

• The Australian Clinical Guidelines for Stroke Management (2010) and New Zealand Clinical Guidelines for Stroke Management (2010) scored highest in both AGREE II and ADAPTE evaluations indicative of the highest quality guidelines
• Overall, the majority of documents had limited information pertaining to aphasia management specifically, and often referred to aspects of aphasia management such as assessment of communication disorders in passing or as part of a general multidisciplinary recommendation
• Information about specific aphasia therapy interventions or different service delivery methods was seldom covered within these documents
• The Royal College of Speech and Language Therapists (2005) aphasia guideline provided the most comprehensive coverage for aphasia management, but demonstrated poor methodological rigour in the AGREE II and ADAPTE
• The aphasia chapter of the Evidence-Based Review of Stroke Rehabilitation (Salter et al., 2008) and the ANCDS evidence reviews (Beeson & Robey, 2006) are reviews of different aphasia treatments rather than clinical guidelines.

2. More guidance for aphasia rehabilitation is required

While the Australian Clinical Guidelines for Stroke Management (2010) is a high quality guideline, it does not provide enough detail with regards to aphasia rehabilitation to ensure standardised care.

Formalising patient care through the use of clinical practice guidelines (CPGs) has been found to be one way to directly improve the quality of patient management and optimise outcomes (Grimshaw et al, 1993; Woolf et al, 1999). However, numerous population-based studies demonstrate low compliance with guidelines (Grimshaw et al, 2006; Browman et al, 1995; McGlynn et al , 2003; FitzGerald et al, 2006; Brown et al, 2004;  Latosinksy et al, 2007; Francke et al, 2008).

Opportunities have been identified by which guidelines could be modified to enhance their uptake such as; alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use (Gagliardi et al, 2011). It currently remains unclear how these various implementability features might influence guideline use.

The evidence on the effectiveness of clinical pathways remains mixed (Kwan & Sandercock 2003), however, they do by nature assist in the translation of guidelines or evidence into local structures.

In combination with more detail aphasia management recommendations within the Australian Clinical Guidelines for Stroke Management, clinicians would have enhanced access to information to assist in maintaining best practice, consumers could obtain best service and policy makers can recommend and judge services across the continuum of care.

A pathway has the potential to provide enhanced aphasia management recommendations, consumer and clinician perspectives along with structured support in how to implement it. Integrated care pathways aim to bring together all available evidence in a coherent and comprehensive system.

Within the context of aphasia, a pathway would ensure that all people with aphasia and their families receive the most up-to-date and scientifically-informed approach to care as well as providing a structure and mechanism for rapidly responding to, and broadly disseminating, new research-based developments.

What is the aim of the AARP?

The AARP aims to improve the overall journey for people with aphasia and their family/friends through providing clinicians with access to the best evidence in a dynamic and user-friendly format.

What theories and principles underpin the AARP?

The AARP utilises the concepts of evidence-based practice (EBP). EBP is a perspective on clinical decision-making that emphasises the need to integrate patient values and preferences along with best current research evidence and clinical expertise in making clinical decisions Guyatt et al., 2000 (Journal article); Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000 ( Book). ASHA – Evidence-Based Practice. Recent definitions of EBP also tend to include an additional aspect involving information from the practice context (see Figure 2).

The AARP is also underpinned by the principles of knowledge transfer and exchange (KTE) which aims to close the research-practice gap in order to realise and maximise the benefits of research within the practice setting. A knowledge synthesis design within a Knowledge Transfer and Exchange (KTE) framework by Graham et al (2006) adapted for aphasia rehabilitation has been utilised (Power et al., 2012) (see Figure 2).

The structure and content of the AARP is influenced by the World Health Organization’s (WHO) International Classification of Function, Disability and Health, commonly known as the ICF. The ICF is a classification of health and health-related domains including; body functions and structure, activity and participation. Contextual factors are also included through a list of environmental factors and personal factors. 

How were the Best Practice Statements formed?

The RAND/UCLA Appropriateness Method (RAM) (Fitch, 2001) was utilised to combine best available scientific evidence with the collective judgment of experts. The empirical evidence was synthesised across eight areas of aphasia care. Experts in each area assisted in translating the evidence into a list of best practice statements. Each statement was accompanied with a summary of the research and the ‘level of evidence’ according to the NHMRC’s levels of evidence (NHMRC, 2010).

A national expert panel of nine leading aphasia researchers and clinicians was developed. The nine members represented geographical diversity as well as a wide variety of clinical and research expertise (across the acute, subacute and community levels of care). Between October and December 2013, two rating rounds (one via email and one face-to-face) occurred. During the first round, the panelists rated each statement on a scale of 1-9, with 9 being the most ‘appropriate’ as per the RAM manual. During the second round, the panel met face-to-face and each statement was discussed individually. Those statements that achieve a high level of agreement and an overall median score of 7-9 were rated as ‘appropriate’ and constitute a set of clear, evidence-based and expert-endorsed Best Practice Statements for aphasia rehabilitation.

References

Rohde, A., Worrall, L., Le Dorze, G., (2012).  Analysis of the quality of clinical guidelines for aphasia in stroke management. Journal of Evaluation in Clinical Practice.