Local clinical pathways: from ‘good ideas’ to ‘practicality’ for general practitioners

Abstract

INTRODUCTION There has been increased interest in the utility of clinical pathways by primary health care in New Zealand, although evaluation of their use has been limited. AIM To identify barriers and facilitators for the use of clinical pathways in one health region. METHODS Interviews with 15 general practitioners in the Western Bay of Plenty. A qualitative thematic analysis was undertaken, informed by the Diffusion of Innovation Framework. RESULTS Four themes were identified: learning to use the pathways, persuasion and decision to use, implementation and sustainability. Barriers to using the pathways included time pressure; scepticism; difficulty in portraying patients’ clinical picture within a set pathway; technical difficulties and lack of support in obtaining knowledge; and practical implementation of the pathways in daily work. Facilitators included endorsement by opinion leaders; pathways directing workup and treatment stepwise towards referral; centralised information with resources available in the consultation; and reported increased acceptance of referrals by secondary care if pathways were used. DISCUSSION The development and implementation of health care initiatives requires an understanding of the local context. Knowledge about the specific, locally appreciated barriers and facilitators can inform future health-care developments. The Diffusion of Innovation Framework offers a practical model to understand effective implementation.

Exploring clinician perceptions of a care pathway for the management of shoulder pain: a qualitative study

“…Our findings support the results of previous qualitative studies that identified barriers and facilitators for using and implementing clinical pathways in healthcare settings [ 4 , 38 – 40 ]. For example, a qualitative study by Reyneke, et al [ 4 ] aimed to identify barriers and facilitators of general practitioners using clinical pathways in a primarily urban health region in New Zealand. The care pathways were web-based flow diagrams directing practitioners to treatment modalities available in the community.…”

“…In addition, care pathways support the mutual decision-making between patients and clinicians [ 2 ]. Conceptually, the growing body of literature supports the use of care pathways; however, their development and dissemination alone are not enough to meaningfully impact practice behaviour [ 3 , 4 ]. Significant individual, systems, and contextual barriers along with awareness and lack of familiarity may hinder the uptake of care pathways and associated clinical recommendations in practice settings [ 5 – 7 ].…”

“…For instance, hesitancy to implement new evidence may be due to limited organizational support, conflicting information between sets of guidelines, and reluctance to change currently offered interventions to patients, especially when there appears to be anecdotal evidence of effectiveness [ 8 ]. Furthermore, clinicians may be hesitant to implement clinical care pathways because of perceived loss of autonomy over their clinical decision-making [ 4 , 9 , 10 ].…”

From the Editor: Reading, writing and research impact

“…13 Further relating to the practical use of guidelines, Reyneke, Jaye and Stokes examine the process of accepting and using care pathways in the Western Bay of Plenty. 14 We also have an array of papers about health care services. Nixon shows how point of care ultrasounds in rural hospitals influence generalist physicians' decision-making.…”

Referrals from primary care to community mental health teams: what’s missing?

“…health.nz/about-us/key-projects-and-initiatives) has the potential to improve the quality of referrals, but there is currently no guideline within Healthpathways for mental health services. 18,19 There are also no New Zealand-based studies relating to the content and quality of referrals from primary care to specialist mental health services. The objective of this study was to evaluate content of referral letters, using an audit tool.…”