You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries
Abstract 1:
Objective To assess the between hospital variation in use of guideline recommended treatments and clinical outcomes for acute myocardial infa rct ion in Sweden and the United Kingdom . Design Population based longitudinal cohort study using nationwide clinical registries . Setting and participants Nationwide registry data comprising all hospitals providing acute myocardial infa rct ion care in Sweden ( SWEDEHEART/RIKS-HIA , n=87 ; 119 786 patients ) and the UK ( NICOR/MINAP , n=242 ; 391 077 patients ) , 2004 - 10 . Main outcome measures Between hospital variation in 30 day mortality of patients admitted with acute myocardial infa rct ion . Results Case mix st and ardised 30 day mortality from acute myocardial infa rct ion was lower in Swedish hospitals ( 8.4 % ) than in UK hospitals ( 9.7 % ) , with less variation between hospitals ( interquartile range 2.6 % v 3.5 % ) . In both countries , hospital level variation and 30 day mortality were inversely associated with provision of guideline recommended care . Compared with the highest quarter , hospitals in the lowest quarter for use of primary percutaneous coronary intervention had higher volume weighted 30 day mortality for ST elevation myocardial infa rct ion ( 10.7 % v 6.6 % in Sweden ; 12.7 % v 5.8 % in the UK ) . The adjusted odds ratio comparing the highest with the lowest quarters for hospitals ’ use of primary percutaneous coronary intervention was 0.70 ( 95 % confidence interval 0.62 to 0.79 ) in Sweden and 0.68 ( 0.60 to 0.76 ) in the UK . Differences in risk between hospital quarters of treatment for non-ST elevation myocardial infa rct ion and secondary prevention drugs for all discharged acute myocardial infa rct ion patients were smaller than for reperfusion treatment in both countries . Conclusion Between hospital variation in 30 day mortality for acute myocardial infa rct ion was greater in the UK than in Sweden . This was associated with , and may be partly accounted for by , the higher practice variation in acute myocardial infa rct ion guideline recommended treatment in the UK hospitals . High quality healthcare across all hospitals , especially in the UK , with better use of guideline recommended treatment , may not only reduce unacceptable practice variation but also deliver improved clinical outcomes for patients with acute myocardial infa rct ion . Clinical trials registration Clinical trials NCT01359033


Title 2:
Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?
Abstract 2:
UNLABELLED Aim Integrated care pathways ( ICP ) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities . ICPs are now being implemented across international healthcare arena , but evidence to support their use is equivocal . The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner . This can lead to improvements in service quality and service efficiency without adverse consequences for patients . 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice . 3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals . 4 ICPs can be effective in improving physician agreement about treatment options . 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide . 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new . 7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction . 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories . 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established . 10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others . 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits . 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture . 13 ICP documentation can introduce scope for new kinds of error . Conclusions ICPs are most effective in context s where patient care trajectories are predictable . Their value in setting s in which recovery pathways are more variable is less clear . ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain . None of the studies review ed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation


Title 3:
Global case management: using the case management model for the care of patients with acute myocardial infarction in a military hospital in Turkey.
Abstract 3:
This study was planned in an experimental manner to use the " case management model " for the care of patients with acute myocardial infa rct ion ( MI ) , and to determine the effect of this method on the quality of care , patient and nurse satisfaction , and the patient 's inpatient duration at the hospital . Data for the study were obtained using the Patient Information Form , Acute MI Care Protocol ( Clinical Pathway ) , Care Monitoring Scale and Scoring Form , Acute MI Nursing Care Plan , Patient Education Booklet , and a Patient and Nurse Satisfaction Evaluation Survey . Evaluation results showed that the patient group where the case management model was used had increased quality of care , decreased inpatient stay , and increased satisfaction of the patient and the nurse . Therefore , it was suggested that the case management model be used in healthcare institutions in Turkey , care protocol s for various diagnoses be developed , and nurses should be trained as case managers to increase the quality of care at healthcare institutions


Title 4:
Clinical pathways--an evaluation of its impact on the quality of care in an acute care general hospital in Singapore.
Abstract 4:
A critical or clinical pathway defines the optimal care process , sequencing and timing of interventions by healthcare professionals for a particular diagnosis or procedure . It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals and various healthcare organisations in many parts of the world . It is now slowly gaining momentum and popularity in Asia and Singapore . Clinical pathways are developed through collaborative efforts of clinicians , case managers , nurses , and other allied healthcare professionals with the aim of improving the quality of patient care , while minimising cost to the patient . Clinical pathways have been shown to reduce unnecessary variation in patient care , reduce delays in discharge through more efficient discharge planning , and improve the cost-effectiveness of clinical services . The approach and objectives of clinical pathways are consistent with those of total quality management ( TQM ) and continuous clinical quality improvement ( CQI ) , and is essentially the application of these principles at the patient 's bedside . However , despite the growing popularity of pathways , their impact on clinical outcomes and their clinical effectiveness remains largely untested and unproven through rigorous clinical trials . This paper begins with an overview of the nature of clinical pathways and the analysis of variances from the pathway , their benefits to the healthcare organisation , their application as a tool for CQI activities in direct relation to patient care , and their effectiveness in a variety of healthcare setting s. The paper describes an evaluation of the impact of a clinical pathway on the quality of care for patients admitted for uncomplicated acute myocardial infa rct ion ( AMI ) through an analysis of variances . The author carried out a one year evaluation of a clinical pathway  on uncomplicated AMI in Changi General Hospital ( CGH ) to determine its effectiveness and impact on a defined set of outcomes . A before and after nonr and omized study of two groups of patients admitted to the Hospital for uncomplicated AMI was done . A total of 169 patients were managed on the clinical pathway compared to 100 patients in the control ( historical comparison ) group .  Outcomes were compared between the two groups of patients . Restriction and matching of study subjects in both groups ensured that the patients selected were comparable in terms of severity of illness . The results showed that the patients on the clinical pathway and the comparison group were similar with respect to demographic variables , prevalence of risk factors and comorbidities . There was a statistically significant reduction in the average length of stay after implementation of the clinical pathway . This was achieved without any adverse effect on short term clinical outcomes such as in-hospital mortality , complication rate and morbidity . There were no significant difference in readmission rates at 6 months after discharge . The paper concludes that clinical pathways , implemented in the context of an acute care general hospital , is able to significantly improve care processes through better collaboration among healthcare professionals and improvements in work systems


Title 5:
Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction
Abstract 5:
Objectives : To study the care pathway effect on the percentage of patients with ST-elevation myocardial infa rct ion ( STEMI ) receiving timely coronary reperfusion  and the percentage of STEMI patients receiving optimal secondary prevention .  Methods : A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement . One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion . Adjusted ( hospital r and om intercepts and controls for transfer and out-of-office admission ) differences in composite outcomes were analyzed by a multilevel logistic regression . Results : Significant improvements in intervals between the first medical contact ( FMC ) to percutaneous coronary intervention ( PCI ) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits . Six out of nine outcomes were significantly poorer in the case of transfer . The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours . Conclusions : After care pathway implementation , composite outcomes improved for in-hospital STEMI care . Collaborative efforts exploited heterogeneity in performance between hospitals . Iterative and incremental care pathway implementation maximized performance improvement


Title 6:
Defining barriers and enablers for clinical pathway implementation in complex clinical settings
Abstract 6:
Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs , their true impact has been limited by variable implementation strategies and suboptimal research design s. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department setting s. Methods This descriptive , qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario , Canada . As part of our larger cluster r and omized controlled trial , each site was in the preparation phase to implement one of two clinical pathways : pediatric asthma or pediatric vomiting and diarrhea . Data were collected from three sources : ( i ) a mediated group discussion with site champions during the project launch meeting ; ( ii ) a semi-structured site visit of each emergency department ; and ( iii ) key informant interviews with an administrative lead from each hospital . The Theoretical Domains Framework ( TDF ) was used to guide the interviews and thematically analyze the data . Domains within each major theme were then mapped onto the COM-B model — capability , opportunity , and motivation — of the Behaviour Change Wheel . Results Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation . Within two themes , three distinct levels of impact emerged , namely ( i ) the individual health professional , ( ii ) the emergency department team , and ( iii ) the broader hospital context . The TDF domains occurring most frequently were Memory , Attention and Decision Processes , Environmental Context and Re sources , Behavioural Regulation , and Reinforcement . Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting . Several factors were viewed as both negative and positive across different perspectives . Two of the seven themes were limited to one component , while four involved all three components of the COM-B model . Conclusions Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED setting s. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change . Trial registration Clinical Trials.gov , NCT01815710


Title 7:
Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?
Abstract 7:
OBJECTIVE The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infa rct ion ( AMI ) clinical pathway ( CPW ) on thrombolytic administration in rural emergency departments . DESIGN Cluster r and omised controlled trial . SETTING Six rural Victorian emergency departments participated . INTERVENTION The five-step CPW implementation process comprised ( i ) engaging clinicians ; ( ii ) CPW development ; ( iii ) reminders ; ( iv ) education ; and ( v ) audit and feedback . MAIN OUTCOME MEASURES The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic  and time to thrombolysis and electrocardiogram .  RESULTS Nine hundred and fifteen medical records were audited , producing a final sample of 108 patients eligible for thrombolysis . There was no significant difference between intervention and control groups for median door-to-needle time ( 29 mins versus 29 mins ; P = 0.632 ) , proportion of those eligible receiving a thrombolytic ( 78 % versus 84 % ; P = 0.739 ) , median time to electrocardiogram ( 7 mins versus 6 mins ; P = 0.669 ) and other outcome measures . Results showed superior outcome measures than other published studies . CONCLUSIONS The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample . Results suggest that quality of AMI treatment in rural emergency departments ( EDs ) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas
One study was a r and omized controlled trial , 14 were pre design s and post design s , and two were longitudinal observational design s. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times .
Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional re sources and costs .