Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review

Abstract

Background: Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered. The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC). Methods: A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed. Results: Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied. The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multidisciplinary communication and individual tailored interventions were identified as facilitators.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

“…We found similarities with the barriers that had previously been found in research studies related to the barriers to the implementation of CPGs, and more specifically to the implementation of the BFHI [ 10 , 11 , 12 , 14 ]. In a prominent manner, and above the other barriers at the level of the health organizational system context, the lack of human, physical and time resources was highlighted.…”

“…There is also a perception transmitted by all the clinical profiles and managers regarding the insufficient participation of the doctors in the implementation of the CPG. There are research studies that coincide with this finding, and they relate this to a lack of incentives [ 41 ], the feeling of loss of control of their function, or the obligation to make important changes [ 11 , 42 ]. The lack of knowledge and training on breastfeeding has also been pointed out [ 43 ].…”

“…The lack of attitude and motivation among health professionals with respect to the subject of breastfeeding has been pointed out in particular, indicating that the work performed was not recognized. The lack of motivation and the negative attitudes towards certain interventions and the lack of professional recognition was related to the lack of compliance of the recommendations of the CPG [ 11 , 28 , 32 ]. Additionally, aspects related to inter-professional perceptions had an important presence among the barriers in the health professional context.…”

“…A systematic meta-review which included 25 systematic reviews published until 2017 [ 9 ] and three systematic reviews published posteriorly [ 10 , 11 , 12 ] underline as the main barriers the aspects related to: political and social context, such as lack of leadership and lack of coordination by the team; health organizational system context, such lack of staffing, and economic and time resources; clinical practice guideline context, such as recommendations that are not clear, and doubts about the quality of the evidence and rigidity; health professional context, such as lack of knowledge about the CPGs, negative attitude, and clinical inertia of practice and the belief that it is not part of one’s role; and patient context, such as lack of knowledge of the patients about the guidelines, the characteristics of the system and their illness, expectations that are contrary to the doctor’s, and lack of family support. The barriers highlighted in these systematic reviews are generally linked with the implementation of CPGs directed at interventions for the treatment of frequent pathologies and chronic diseases [ 10 , 11 , 12 ]. The studies on the implementation of CPGs of health promotion such as BF are less common, and have been mainly studied in environments of primary care and on aspects related to the prevention of chronic health problems and the implementation of practices related to lifestyle changes [ 13 ].…”

Development of a complex intervention to improve mobility and participation of older people with vertigo, dizziness and balance disorders in primary care: a mixed methods study

“…Due to the heterogeneity of the included studies, a narrative synthesis across all types of interventions was conducted concerning the outcome measures covering aspects of the International Classification of Functioning, Disability and Health (ICF) [ 25 ], quality of life and general health. Second, barriers to and facilitators of successful implementation of multi-professional CPWs in primary care were investigated [ 26 ]. Due to the large diversity of study characteristics, interventions and outcomes, we carried out a narrative synthesis following the guidance for undertaking reviews in health care from the Centre for Reviews and Dissemination [ 27 ].…”