Pearson and colleagues [1] succinctly reviewed the processes of developing and implementing critical pathways. As the authors state, critical pathways used to reduce costs while maintaining or improving the quality of care have recently emerged as an important initiative. The authors lament that there are no collaborative efforts to develop critical pathways at the regional or national level in the United States, but such a process is on-going in Canada.

The Clinical Quality Improvement Network was formed in 1991 and now includes nine sites across Canada. Our network of community-based and hospital-based health care researchers is dedicated to evaluating and improving the effectiveness and appropriateness of randomized clinical trial results as applied to whole populations at risk. As a first step, we found that doing pattern-of-practice analyses to define current practice and publishing the results in juxtaposition to the evidence from randomized controlled trials led to increased use of efficacious therapy and enhanced survival outcomes in acute myocardial infarction [2]. We then found that the initiation of a critical pathway for the management of acute myocardial infarction (as part of the standard physician order sheet) led to continued improvement in practice patterns and reduced mortality rates [3]. As discussed by Pearson and colleagues [1], we found that including local clinicians in the development of the critical pathway enhanced its dissemination throughout the network.

Similar processes of practice pattern analysis and critical pathway development and dissemination have been completed for congestive heart failure, atrial fibrillation, and hypercholesterolemia, and process measurement and analysis of the effects of the critical pathways are now under way. We expect that these analyses will confirm the effectiveness of critical pathways in reducing small area variations and optimizing medical care. We believe that if health care research is to enhance clinical practice and outcomes, broad networks of clinicians in various geographic and health care settings must be involved.