DAMPAK PEMBERLAKUAN CLINICAL PATHWAY TERHADAP KUALITAS PELAYANAN STROKE DI RS BETHESDA YOGYAKARTA
Tiara Kusumaningtyas, Prof. dr. Adi Utarini, M.Sc.,MPH, Ph.D.
2013 | Tesis | S2 Ilmu Kesehatan MasyarakatLatar belakang: Stroke masih menjadi masalah kesehatan dunia. Dibutuhkan solusi manajemen klinis yang lebih baik guna mengupayakan pelayanan stroke yang berkualitas. Sebagai sebuah instrumen yang menstandarisasi proses dan outcome pelayanan, clinical pathway selayaknya mampu menjadi solusi perbaikan manajemen kualitas berkelanjutan. Hingga kini bukti mengenai efektivitas clinical pathway masih diperdebatkan. Tujuan: Untuk mengevaluasi dampak clinical pathway terhadap perbaikan kualitas pelayanan stroke berdasarkan indikator proses dan outcome. Metode: Metode yang digunakan dalam penelitian ini adalah metode before-after without control group quasi exsperimental, dimana dilakukan penilaian pre dan post implementasi pada dua kelompok tanpa randomisasi. Kelompok intervensi adalah kelompok subyek yang ditatalaksana dengan clinical pathway sedangkan kelompok kontrol adalah kelompok pasien sebelum pemberlakuan pathway (diambil dari data sekunder rekam medis). Outcome mortalitas sebagai output primer dari penelitian ini akan dibandingkan antara kelompok kontrol dan kelompok intervensi. Hasil: Karakteristik subyek dalam penelitian ini homogeny dalam hal variabel demografi (kecuali jenis kelamin) dan karakteristik klinis gejala wajah perot, faktor risiko dan komorbiditas. Pemberlakuan clinical pathway tidak memperbaiki outcome mortalitas, meskipun proporsi mortalitas menurun, 14,5% sebelum pemberlakuan dan 17,8% setelah pemberlakuan. Clinical pathway secara signifikan memperbaiki proses pelayanan stroke pada esesmen menelan (p=0,00), esesmen rehabilitasi (p=0,00) dan edukasi saat pasien pulang (p=0,001). Jenis stroke, kondisi kesadaran saat pasien masuk RS, adanya faktor risiko DM dan AF meningkatkan risiko mortalitas pasien stroke, sedangkan pelaksanaan esesmen menelan sesegera mungkin menurunkan risiko mortalitas. Kesimpulan: Pemberlakuan clinical pathway pada pelayanan stroke memperbaiki proses pelayanan meskipun dampaknya terhadap outcome mortalitas tidak berpengaruh.
Background: Stroke is one of the major health problems worldwide. A good clinical management system is needed to improve the quality of stroke care. Clinical pathway has tremendous appeal as an integrated approach to improve quality of stroke care by reducing unnecessary variation in process and outcome. However the evidences of the impact of clinical pathway on the quality of stroke care remain questionable. Purpose: To evaluate whether clinical pathway could improve the quality of stroke care by using processes and outcome performance indicators. Method: This study uses before-after test without control group quasi-experimental method. The subjects are ischemic and hemorrhagic stroke patients admitted to the Stroke Unit in Bethesda Hospital. A total of 844 patients were managed on the clinical pathway compared to patients who were managed with standard care. Indicators of performances were compared (historical comparison) between the two groups of patient. Restriction and matching of study subjects in both groups ensured thus the patients selected were comparable in terms of severity of illness. Result: The results showed that the patients on the clinical pathway and the comparison group were similar with respect to demographic variables (except sex), prevalence of risk factors and facial muscle defisit symptom. Following pathway implementation, there was no statistically significant difference on the impact of clinical pathway on stroke mortality outcome. In hospital mortality was 14,5% prior to the pathway and 17,8% after the pathway. The implementation of stroke care pathway is able to significantly improve some care processes; increases in the rates of swallow assessment (p=0.00), rehabilitation assessment (p=0,00) and education at discharge (p=0,001). There is strong correlation between stroke type, level of consciousness, co morbidities of diabetes mellitus and atrial fibrillation and initial swallowing assessment with mortality. Conclusion: Stroke care pathway appeared to improve the process of care, although it has no benefit for mortality outcome.
Kata Kunci : Clinical pathway, manajemen mutu, kualitas pelayanan stroke, outcome stroke, mortalitas, Clinical pathway, continuous quality improvement, quality of stroke care, stroke outcome, mortality
