Clinical Pathway Implementation and Hospital Outcomes Among Bronchopneumonia Patients Under the JKN System in Indonesia

  • Yulia Pitriani Magister Program in Hospital Administration in Public Health Sciences, Faculty of Public Health, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia. Pertamina Brain and Heart Hospital Makassar, Sulawesi Selatan, Indonesia
  • Noer Bahry Noor Faculty of Public Health, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
  • Irwandy Irwandy Faculty of Public Health, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
  • A. Indahwaty Sidin Faculty of Public Health, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
  • Fridawaty Rivai Faculty of Public Health, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
DOI: https://doi.org/10.56338/mppki.v9i8.11390
Keywords: Clinical Pathway, LOS, Hospital Cost, Quality of Care, JKN

Abstract

Introduction: Under Indonesia’s National Health Insurance (JKN) system, hospitals are expected to improve efficiency while maintaining quality of care. Clinical pathways (CPs) are widely implemented to standardize patient management, but evidence regarding their association with hospital outcomes among bronchopneumonia patients remains limited. This study examined the association between CP implementation and hospital outcomes under the JKN system.

Methods: A retrospective analytic study with a cross-sectional design was conducted using secondary data obtained from medical records of 113 JKN inpatients diagnosed with bronchopneumonia at Pertamina Brain and Heart Hospital Biringkanaya Makassar, Indonesia. CP implementation was classified as compliant or non-compliant based on documented adherence to the established clinical pathway. Hospital outcomes included length of stay (LOS), hospital cost efficiency, quality of care, and patient recovery. Data were analyzed using chi-square tests, Mann–Whitney U test, and multivariable binary logistic regression adjusted for age group and sex.

Results: After adjustment for age group and sex, clinical pathway compliance remained independently associated with shorter length of stay (AOR = 15.23; 95% CI: 5.74-40.41; p < 0.001) and greater hospital cost efficiency (AOR = 18.36; 95% CI: 6.77-49.83; p < 0.001). Clinical pathway compliance was also significantly associated with compliance with documented clinical service standards (OR = 140.800; 95% CI: 17.814–1112.876; p < 0.001). Median hospital treatment costs differed significantly between the compliant and non-compliant groups (Mann–Whitney U test, p < 0.001). No significant association was observed between clinical pathway compliance and patient recovery outcomes (p = 0.250).

Conclusion: Clinical pathway compliance was independently associated with shorter LOS, greater hospital cost efficiency, and better adherence to documented clinical service standards. These findings support the role of clinical pathways in promoting standardized and efficient hospital care under Indonesia’s JKN system.

Downloads

Download data is not yet available.

References

  1. Mahasar Reinheart F. Damanik, Aloysius Liliweri, William Djani, I Putu Yoga Bumi Pradana. Evaluating EMR Adoption and Its Effect on Organizational Performance: A Quantitative Study Using SEM-PLS in Type-C Hospitals in Kupang City. Media Publ Promosi Kesehat Indones [Internet]. 2025 Jul 3;8(7):448–66. https://doi.org/10.56338/mppki.v8i7.7458
  2. Rotter T, Koch R, Kugler J, Gothe H, Kinsman L, James E. Clinical Pathways: Effects on Professional Practice, Patient Outcomes, Length of Stay and Hospital Costs. In: Rotter T, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2007. https://doi.org/10.1002/14651858.CD006632
  3. Romeyke T, Stummer H. Clinical Pathways as Instruments for Risk and Cost Management in Hospitals - A Discussion Paper. Glob J Health Sci [Internet]. 2012 Feb 29;4(2):50–9. https://doi.org/10.5539/gjhs.v4n2p50
  4. Heymans MJ, Kort NP, Snoeker BA, Schotanus MG. Impact of Enhanced Recovery Pathways on Safety and Efficacy of Hip and Knee Arthroplasty: A Systematic Review and Meta-analysis. World J Orthop [Internet]. 2022 Mar 18;13(3):307–28. https://doi.org/10.5312/wjo.v13.i3.307
  5. Rusydi AR, Palutturi S, Noor NB, Pasinringi SA. The Implementation of Good Corporate Governance (GCG) at Public Hospital in Indonesia: A literature Review. Enfermería Clínica [Internet]. 2020 Jun; 30:145–8. https://doi.org/10.1016/j.enfcli.2019.10.057
  6. De Bleser L, Depreitere R, Waele K De, Vanhaecht K, Vlayen J, Sermeus W. Defining pathways. J Nurs Manag [Internet]. 2006 Oct;14(7):553–63. https://doi.org/10.1111/j.1365-2934.2006.00702.x
  7. Kornadi, Pasinringi SA, Rivai F, Saleh LM, Hadju V, Irwandy, et al. Assessment of Strategic Healthcare Development Using Importance-Performance Analysis: A Multicenter Study of Three Sharia Hospitals in Indonesia. Heal Leadersh Qual Life [Internet]. 2025 Jul 7; 4:714. https://doi.org/10.56294/hl2025714
  8. Kementerian Kesehatan Republik Indonesia. Pedoman pelaksanaan INA-CBG dalam Jaminan Kesehatan Nasional [Internet]. Jakarta; 2021. Available from: https://jdih.djsn.go.id/
  9. Subekti R, Nurwahyuni A. Analysis of length of stay efficiency as a hospital performance indicator under INA-CBGs reimbursement system. In: Proceedings of the International Conference on Public Health [Internet]. Solo, Indonesia: KnE Life Sciences; 2019. p. 215–22. https://doi.org/10.18502/kls.v4i10.5238
  10. Asmara AAW, Akhmad Safi’i, Ade Armada Sutedja, Achmad Zakaria. Clinical Pathway dan Dampaknya terhadap Lama Rawat Inap (Los) dan Efektivitas Biaya di Rumah Sakit: Tinjauan Literatur. J Penelit Perawat Prof [Internet]. 2025;7(3):551–60. Available from: https://jurnal.globalhealthsciencegroup.com/index.php/JPPP/article/view/6735
  11. Panella M. Reducing Clinical Variations with Clinical Pathways: Do Pathways Work? Int J Qual Heal Care [Internet]. 2003 Dec 1;15(6):509–21. https://doi.org/10.1093/intqhc/mzg057
  12. Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated Care Pathways. BMJ [Internet]. 1998 Jan 10;316(7125):133–7. https://doi.org/10.1136/bmj.316.7125.133
  13. Vanhaecht K, Bollmann M, Bower K, Gallagher C, Gardini A, Guezo J, et al. Prevalence and use of clinical pathways in 23 countries - an international survey by the European Pathway Association. Int J Care Pathways [Internet]. 2006 Apr 1;10(1):28–34. https://doi.org/10.1258/j.jicp.2006.124
  14. Lawal AK, Rotter T, Kinsman L, Machotta A, Ronellenfitsch U, Scott SD, et al. What is a Clinical Pathway? Refinement of an Operational Definition to Identify Clinical Pathway Studies for a Cochrane Systematic Review. BMC Med [Internet]. 2016 Dec 23;14(1):35. https://doi.org/10.1186/s12916-016-0580-z
  15. Ramayani N, Rosyidah R, Hidayat MS. Implementasi Clinical Pathway Terhadap Mutu, Biaya dan Varians Pelayanan: Suatu Studi Literatur. J Formil (Forum Ilmiah) Kesmas Respati [Internet]. 2024 Jan 31;9(1):32. https://doi.org/10.35842/formil.v9i1.533
  16. Siswanto M, Chalidyanto D. The Effect of Clinical Pathway Compliance in Reducing Length of Stay. J Adm Kesehat Indones [Internet]. 2020 May 20;8(1):65–77. https://doi.org/10.20473/jaki.v8i1.2020.65-77
  17. van Hoeve JC, Vernooij RWM, Fiander M, Nieboer P, Siesling S, Rotter T. Effects of Oncological Care Pathways in Primary and Secondary Care on Patient, Professional and Health Systems Outcomes: a Systematic Review and Meta-analysis. Syst Rev [Internet]. 2020 Dec 25;9(1):246. https://doi.org/10.1186/s13643-020-01498-0
  18. Rotter T, Kugler J, Koch R, Gothe H, Twork S, van Oostrum JM, et al. A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes. BMC Health Serv Res [Internet]. 2008 Dec 19;8(1):265. https://doi.org/10.1186/1472-6963-8-265
  19. Rezeki SF, Pasinringi SA, Rivai F, Saleh LM, Irwandy I, Ansariadi A, et al. Value Innovation in Hospital: A Systematic Review. Univers J Public Heal [Internet]. 2025 Mar;13(2):345–53. https://doi.org/10.13189/ujph.2025.130207
  20. Fadilah NFN, Budi SC. Efektifitas Implementasi Clinical Pathway terhadap Average Length of Stay dan Outcomes Pasien DF-DHF Anak di RSUD Kota Yogyakarta. J Kesehat Vokasional [Internet]. 2018 May 21;2(2):175. https://doi.org/10.22146/jkesvo.30333
  21. Sidin AI, Dessy Nugraheni C, Rivai F, Pasinringi SA, Hamzah HA. Transformational Leadership on Patient Safety Culture in the Beriman Balikpapan Regional Hospital. Front Heal Informatics [Internet]. 2024;13(8):2734–7. Available from: https://healthinformaticsjournal.com/index.php/IJMI/article/view/1928
  22. Aprilani D, Rivai F, Maidin A, Bahry Noor N, Muhammad L, Hamzah H. The Effect of Perceived Organizational Support and Organizational Commitment to Organizational Citizenship Behavior Nurse Dr. Tadjuddin Chalid. Turkish J Comput Math Educ [Internet]. 2021;12(12):4138–46. Available from: https://turcomat.org/index.php/turkbilmat/article/view/8251
  23. Rezkiki F. Pengaruh Penerapan Nursing Clinical Pathway terhadap Lama Hari Rawat Pasien Stroke Non Hemoragik. J Ipteks Terap [Internet]. 2018 Mar 31;12(1):9. https://doi.org/10.22216/jit.2018.v12i1.1158
  24. Bierrum W, Spencer JI, Macarimban R, Shirazi A, Dethabrew AU, See I, et al. Novel Pathways for Headache Via Neurology Same Day Emergency Care: Admission Avoidance, Prevention of Lumbar Punctures and Reduced Length of Stay in Hospital. BMJ Open Qual [Internet]. 2024 Dec 31;13(4): e003036. https://doi.org/10.1136/bmjoq-2024-003036
  25. Rahmat Alyakin Dakhi, Manurung J, Dachi AC. Organizational and Behavioral Factors Associated with Infection Prevention and Control Policy Implementation among Nurses: A Cross-Sectional Study in a District Hospital. Media Publ Promosi Kesehat Indones [Internet]. 2026 May 6;9(5):1074–83. https://doi.org/10.56338/mppki.v9i5.10602
  26. Indra Nur Fauzi, Fendy Suhariadi, Albertus Eka Putra Hariyanto, Erlyn Yuly Astuti. Performance of Muhammadiyah Hospital as Social Entrepreneurship Organization: The Role of Leadership Effectiveness. Media Publ Promosi Kesehat Indones [Internet]. 2025 Jan 15;8(1):56–69. https://doi.org/10.56338/mppki.v8i1.6649
  27. Karunakaran M, Jonnada PK, Barreto SG. Systematic Review and Meta-analysis of the Impact of Deviations from a Clinical Pathway on Outcomes Following Pancreatoduodenectomy. World J Clin Cases [Internet]. 2021 May 6;9(13):3024–37. https://doi.org/10.12998/wjcc.v9.i13.3024
  28. MdSharif S, Ab Rahman J, Abdul Latif H, Anida Awang R, Daud M, Fadzil Abdullah A, et al. Paediatric Asthma Clinical Pathway: Impact on Cost and Quality of Care. Med J Malaysia [Internet]. 2019;74(2):138–44. https://pubmed.ncbi.nlm.nih.gov/31079125/
  29. Sari N, Omar M, Pasinringi SA, Zulkifli A, Sidin AI, Irwandy I, et al. Toward Hospital Resilience: a Qualitative Study on the Identification of Hospital Shocks During Disruption Era in Indonesia. BMC Health Serv Res [Internet]. 2024;24(1):1185. https://doi.org/10.1186/s12913-024-11385-2
  30. Fitria A, Armani AS, Rochmah TN, Purwaka BT, Pudjirahardjo WJ. Penerapan Clinical Pathways sebagai Instrumen Pengendalian Biaya Pelayanan : Studi Penelitian Tindakan Penderita BPJS yang Menjalani Operasi Caesar dengan Sistem Pembayaran INA-CBG. J Keperawatan Silampari [Internet]. 2021 Jun 7;4(2):593–9. https://doi.org/10.31539/jks.v4i2.1546
  31. Hijrah H, Saleh A, Rini Rachmawaty. Efektivitas Jalur Klinis Terintegrasi terhadap Lama Hari Rawat dan Biaya pada Pasien Pasca Operasi: Tinjauan Literatur. J Ilm Keperawatan (Scientific J Nursing) [Internet]. 2022 Feb 28;8(1):1–5. https://doi.org/10.33023/jikep.v8i1.787
Published
2026-08-19
How to Cite
Pitriani, Y., Noor, N. B., Irwandy, I., Sidin, A. I., & Rivai, F. (2026). Clinical Pathway Implementation and Hospital Outcomes Among Bronchopneumonia Patients Under the JKN System in Indonesia. Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 9(8), 1534-1543. https://doi.org/10.56338/mppki.v9i8.11390
Issue
Vol. 9 No. 8 (2026)
Section
Research Article

Copyright (c) 2026 Media Publikasi Promosi Kesehatan Indonesia (MPPKI)

Creative Commons License

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.