The flow diagram of study selection is shown in Fig. 1. The initial literature search identified 15,266 articles. We removed 3064 duplicates and excluded 11,637 articles after screening titles and abstracts. Thirty-two articles from HICs and 448 from UMICs were excluded following a rapid sort by country. Full-text records of 85 articles and 7 additional papers identified through citation tracking were reviewed. In instances where full-text articles were not available, attempts were made to directly contact the author. A total of 27 articles met the inclusion criteria.
Characteristics of sources of evidence
Characteristics of included studies are summarized in Table 1. Over half (n = 15) were published in the last 5 years (2016–2020), and the earliest article is from the year 2000. All studies were conducted in a single country and were from seven different countries: Bangladesh, Egypt, India, Nepal, Pakistan, Uganda and Ukraine. Twenty-four studies (89%) were from lower-middle-income, and 3 (11%) from low-income countries. Just over half (n = 15, 56%) were from India.
The majority of studies were set in third-level institutions (n = 24, 89%), while none were from first-level institutions. Twenty-one articles (78%) reported pathways implemented at a hospital-wide scale. The other six (22%) were at a single perioperative team scale. The specialties in which care pathways were most commonly studied were hepato-pancreaticobiliary (n = 9, 33%), colorectal (n = 7, 26%) and cardiothoracic (n = 4, 15%). The majority of articles reported care pathways for elective surgery (n = 20, 74%). One (4%) article reported exclusively on a pediatric (≤ 18 years) pathway.
The design of included studies was quantitative non-randomized for 12 (44%), quantitative descriptive for 10 (37%) and quantitative randomized controlled for 5 (19%). There were no qualitative or mixed-method studies. Seventeen (63%) studies evaluated pathways against a comparator, most commonly (n = 14) previous standard of care.
Critical appraisal within sources of evidence
Most studies (n = 19, 70%) were of low (MMAT score = 0–2) or medium quality (MMAT score = 3) as outlined in Table 2. Common limitations were failure to meet the criteria ‘Did the participants adhere to the assigned intervention’ and ‘During the study period, is the intervention administered as intended’ for randomized controlled and non-randomized studies, respectively. None of the 5 randomized controlled trials demonstrated that outcome assessors were blinded to the intervention.
Pathway design and clinical interventions
Twenty-three (85%) of the included articles reported ‘adapted’ pathways. Almost all of these referenced ERAS (Enhanced Recovery After Surgery) or Fast-track guidelines as the original source. Two (7%) described pathways that were designed de novo. While fulfilling the inclusion criteria, one study did not provide details of pathway interventions . Owing to the heterogeneity of pathways, no attempt was made to synthesize the nature of reported clinical interventions; however, these are listed in Online Resource 4.
Study aims and outcomes
Five articles (19%) referred to the evaluation of ‘safety’ within the title or study aim and three (11%) used the term ‘feasibility’. Table 3 summarizes the reported outcomes. A total of 375 outcome measures were charted across 27 articles. Of these, physiological and clinical outcomes were most common (n = 182, 49%). Twelve studies (44%) reported a physical functioning outcome, of which most related to early postoperative milestones of drinking, eating and mobilizing. Besides pain assessment, there were only three (1%) patient-reported outcome measures (PROMS); two studies reported mobility scores and one assessed patient satisfaction [29, 30, 35].
Most studies reported a hospital resource use outcome measure (n = 26, 96%), with 25 studies reporting length of hospital stay and 18 reporting readmission rates. Eight articles (30%) described adherence to intervention as an outcome measure. Some provided an overall statistic for compliance; however, only one study offered a detailed breakdown of the adherence to all pathway components .
Pathway implementation strategies
The number of implementation strategies reported by each study ranged from 0 to 9 (median = 2). No strategies were reported in 4 articles (15%). The most frequently reported strategy within each ERIC taxonomy cluster is shown in Table 4. Across 27 articles, 24 of the 73 ERIC strategies were used. The most frequently reported strategies were “Prepare patients/consumers to be active participants” and “Promote adaptability”. There were no strategies that targeted an infrastructure change.
Facilitators and barriers to pathway implementation
Implementation facilitators and barriers according to CFIR construct are summarized in Table 5.
Most articles framed existing literature, almost exclusively from HICs, as a facilitator for implementation and adapted published pathways to the setting and type of surgery. For example, a pathway for pancreatic cancer resections adapted from ERAS recommendations omitted selective preoperative biliary drainage as this was performed elsewhere prior to admission . The ability to trial a pathway on a smaller scale served as a facilitator as some expanded the use of pathways to other types of surgery after first implementing and evaluating a single pathway . Others evaluated a new pathway against current care so that the better model could be used . While a reduction in cost and resource use was a commonly cited advantage of pathway implementation, the cost of interventions was often a barrier. One study reported that financial constraints in Punjab province meant that minimally invasive surgery could not be offered . In India, carbohydrate drinks recommended by ERAS were not commercially available , while thromboprophylaxis and ondansetron (antiemetic) could not be offered in Uganda as these were too expensive .
International guidelines, particularly by the ERAS society, were incorporated into most reviewed pathways and were an important facilitator. One study reported pressure to conform to international standards as a driver for implementation . Institutional prioritization of patient needs facilitated the implementation of some pathways. Earlier return to work afforded by the pathway was cited as a priority for patients and thus an important reason for implementing fast track surgery in an Indian study . A study from Pakistan recognized that when a child is admitted for surgery, the whole family moves close to the hospital, incurring a cost for accommodation . Minimizing the length of hospital stay was therefore hoped to reduce costs for the family. Conversely, a study from Bangladesh described that lack of follow-up services outside the city led patients in the ‘fast track’ pathway to stay near the hospital for at least a week post-discharge .
Cooperation and good team communication were reported as facilitators to implementation [25, 27]. High demand for surgery, performance indicators and the need for efficient use of limited resources created tension for change away from existing care [25, 42, 50]. Two Indian studies conducted in specialized hospitals acknowledged that their existing resources were not representative of most LMIC institutions, where resource constraints could act as a barrier [30, 34]. Indeed, a lack of human resources and funding coupled with increasing patient numbers acted as a barrier in another Indian study .
Characteristics of individuals
Several studies hypothesized that clinician beliefs were the reason pathways were not widely implemented within their countries [33, 38, 48], though this was not reported as a barrier in their institutions. However, early discharge and outpatient surgery were hindered by surgeons’ conservative approach as well as patients’ fear of leaving the safety of a hospital [31, 42].
Literature searches and multidisciplinary consensus meetings were used to design care pathways [29, 40]. Implementation was facilitated by the establishment of improvement teams and allocation of formal roles, including a dedicated supervisor for the entire pathway [30, 44, 46]. Senior clinicians with influence within a department often led implementation [28, 34, 45]. One study reported the use of a formal implementation methodology, the King’s interacting systems framework and theory of goal attainment, as a facilitator . Although all studies reported quantitative outcomes, only one described how this information was used to aid further improvement .