How to build a proper pediatric endocrinology or diabetes PDTA adherent to local realities and how to verify its effectiveness, efficiency, and cost-effectiveness

The articles in the “Expert Opinion” section cover some of the most important and debated topics in their respective clinical areas. Because of the level of depth attained, the texts may contain very complex terms and concepts. Use of the glossary may help in understanding these articles, and other, more popular content on the site will help clarify the topics covered.

The PDTA, or diagnostic-therapeutic-care pathway, is a model of organization that the company or region prepares, proposes and implements in order to manage a series of processes aimed at providing appropriate patient care, relative to a specific disease. It is an economic-business approach to the management of primary processes, i.e., the individual and different health needs of the population to which each specific pathway is addressed, which allows coordination between the world of professions and the corporate managerial world, enabling their operational integration.

PDTAs arise because there is an increasing complexity of health care needs, with expansion of demand in the face of spending constraints: often, in order to have adequate responses to patients’ needs, one cannot limit oneself to the areas of individual operating units or departments, but it is necessary to go beyond the corporate perimeter to create inter-agency clinical networks, which intercept the demands and priorities of a wider pool of patients. In this care system, hub centers can be identified, tasked with managing the most complex and rare diseases, and spoke centers, closer to the territory and able to take charge of the bulk of care demand. For the network system to work, it is crucial that the components of this arrangement accept the different roles in the pathway and share information and incentive and monitoring mechanisms. The PDTA basically aims to overcome what may be individual departmental realities in order to enable a smooth “flow” of the patient through the various “hubs” of the care system by creating an economically sustainable and appropriate system.

Diagnostic-therapeutic-assistance pathways should not be confused with guidelines, protocols and LEAs (essential levels of care): the guideline refers to a specific pathology without taking into account territorial realities; the protocol refers to the diagnosis and/or treatment of a disease, with a binding character for operators, without supporting coordination among the health and managerial figures involved; the LEA indicates the services and facilities that the national health system is required to provide to all citizens, without entering the strictly organizational sphere.

There are PDTAs at the company level, which are generally the most valid because they take into account territorial realities and therefore can adapt the offer to their own capabilities or interact with other companies, health or hospital, to complete the established pathway; then there are the regional ones, in which instead the health authority establishes a priority, defines who participates in the working group that will prepare the pathway and all the parameters necessary for the project to be successful. In the latter case, the regional health authority has a more strategic interest, that of standardizing care for individual diseases as much as possible throughout the region: it will liaise with providers and still maintain control of the care network.

Any PDTA will have to pursue five goals: 1) clinical efficiency, i.e., the right relationship between the resources used and the results obtained; 2) effectiveness, i.e., an adequate relationship between the needs met and the services provided; 3) continuity of services; 4) information sharing; and 5) the centrality of the patient in the care process. These goals will be achieved through several means: a) clinical and behavioral standard in decision-making, which reduces “artificial professional variability,” i.e., different approaches by practitioners dedicated to the same pathology; b) organizational models based on consensus among professionals, in which the logic of competition is balanced by that of collaboration; and c) demand analysis and stratification of clinical and care needs.

The indication of the pathway can start from the corporate management or regional government (top-down system), or from the initiative of the professionals treating a given pathology (bottom-up): in the first case, it will be the corporate or regional top figures who will define the leadership of the program and identify the members of the “technical table” (the multidisciplinary and interdisciplinary working group, i.e., the professional figures in charge of elaborating the pathway); in the second case, it will be the pre-established technical table that will submit the pathway proposal to the company. It is essential to identify the figures involved in the pathway because it involves professionals from different disciplines and profiles, from healthcare personnel in the strict sense (physicians and nurses) to administrative staff (e.g., secretarial service) and management (healthcare management, general management, personnel management area). Having patient-centeredness as the goal of the PDTA, it is important to establish whether patients or a patient association can participate in the creation of the pathway: this is undoubtedly a positive factor because it allows for better measurement of user needs, helps to establish the right therapeutic alliance, and, last but not least, constitutes a brake on the self-referentiality of providers.

Having established the composition and leadership of the experts who will develop the PDTA, the first step in the creation of the pathway (PDTA cycle) will be that of analysis: first, the quantitative assessment of the “phenomenon” is needed, i.e., how many patients can be involved in the program, and this can be deduced from the activity already carried out by the operating units involved, supplemented by the number of co-pay exempt for the pathology subject to the PDTA borne by the company; then, the qualitative analysis (“map of episodes”) is done, i.e., the services currently provided, who provides them and in what manner, their sequence, the decision-making hubs, and what are the patient’s entry and exit points from the current care pathway.

The next stage is the actual design of the PDTA: the working group builds the pathway from the analytical data and defines the standards of care, who will do what, how they should do it and by what means, who will have control over the system, and what will be the parameters (indicators) that will assess its compliance with the basic criteria of each PDTA (appropriateness of supply, continuity of care and economic sustainability). These indicators, taken from evidence-based and experience-based medicine, will have to be measurable, implementable and comparable with similar benchmarks taken from the scientific literature or from the reports of reference health care or hospital companies (benchmarks). The continuous interactive discussion among the professional and managerial figures employed will lead to a virtuous circle that will elevate the quality of care through the acquisition of notions related to pathology, its management, and the uniqueness of the patient, which are often foreign to daily practice.

Once the pathway has been established, we will move on to the change phase, i.e., how to implement what has been planned: with reference to those involved, do training, find additional resources and tools if needed, incentivize them with target (budget) or remunerative models (especially for figures affiliated with the company such as general practitioners or pediatricians of free choice, if included in the pathway).

When the pathway is in place, its monitoring will be established, that is, the periodic review of performance indicators and their discrepancy from benchmarks, so as to correct and overcome inconsistencies from the established model.

In recent years we have seen a massive proliferation of PDTAs, having as their goal the standardization of clinical and organizational processes, but which, in reality, have often limited themselves to legitimizing what was already consolidated, without trying to go and cut inefficiencies and unnecessary costs while guaranteeing the same standard of care; there has been no implementation strategy to change professional behaviors nor adequate monitoring of these processes. Many scientific societies have also felt the need to propose disease-specific PDTAs, which are of no practical use as they do not take into account different territorial realities and are often devoid of indicators: they are therefore little more than suggestions on the appropriateness of care.

In order to “weigh” the quality of a PDTA, it needs to be safe (the patient should not be harmed by adhering to this model rather than the pre-existing one), timely (allow care to be delivered on time), efficient (avoid unnecessary services), effective (prescribe acts and services based on evidence and that in any case produce real benefits), person-centered, and equitable (the pathway must guarantee equal opportunities for everyone who travels this care pathway).

Reference bibliography.

Bergamaschi M, Lecci F. The characteristics of indicators used in planning and control systems in health care. OASI Report 2009.
Morandeo V, Tozzi VD. Population health management and PDTA: “technical evidence of implementation”. OASI Report 2015.
Pacileo G. Lecture on “management by processes in Health Services Companies; PDTAs: logic and scope of application. Hippocrates Course 2021, Bocconi University of Milan.
Tozzi V. Process management in health care. Mecosan 2004;50;71-80.

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