Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study

Abstract

Purpose: Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. Methods: To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. Results: Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. Conclusions: This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

Development and Validity Testing of a Matrix to Evaluate Maturity of Clinical Pathways: A Case Study in Saskatchewan, Canada

“…Clinical pathways, also known as critical or integrated care pathways (8), are operationally de ned as tools to standardize care for a speci c population, translate guidelines or evidence into local structure, create a structured multidisciplinary care plan, and detail a care plan in an inventory of actions (9)(10)(11)(12). Clinical pathways can improve patients' and providers' experience and satisfaction, resource utilization, and inter-professional teamwork while reducing knowledge transition gaps, healthcare team burnout, costs, and variation in care (11,(13)(14)(15). Further, clinical pathways can be utilized to improve the domains of healthcare quality including safety, effectiveness, patientcenteredness, timeliness, e ciency, and equitability (14,16).…”

“…Implementation barriers such as knowledge users' awareness, stakeholders' engagement, information technology (IT) infrastructure, and performance management have been shown to impede optimal integration of clinical pathways into healthcare systems (11)(12)(13)(17)(18)(19). To increase their impact, the development and implementation of clinical pathways should be guided by theories, models, or frameworks (12,20).…”

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians’ mental models

“… 13 , 14 In the primary care context, pathways are often developed by health care authorities, at times in collaboration with family physicians or specialists. 15 – 17 Whereas some studies in Alberta and Canada suggest that family physicians are interested in and follow pathways in their practice, 15 others suggest important challenges related to how pathways might be adopted and used. 18 Some authors report low uptake due to pathway characteristics (format, content), availability and accessibility, 17 , 19 , 20 and family physicians’ practice context.…”

“… 15 – 17 Whereas some studies in Alberta and Canada suggest that family physicians are interested in and follow pathways in their practice, 15 others suggest important challenges related to how pathways might be adopted and used. 18 Some authors report low uptake due to pathway characteristics (format, content), availability and accessibility, 17 , 19 , 20 and family physicians’ practice context. 17 , 20 – 23 However, there is little discussion about how family physicians think and make decisions when presented with pathways, and how pathways fit into their working strategies.…”

“… 18 Some authors report low uptake due to pathway characteristics (format, content), availability and accessibility, 17 , 19 , 20 and family physicians’ practice context. 17 , 20 – 23 However, there is little discussion about how family physicians think and make decisions when presented with pathways, and how pathways fit into their working strategies. In this study, we intended to contribute to that discussion in the context of cancer diagnosis.…”