Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians’ Perspectives of Clinical Pathways

Abstract

Introduction: Healthcare costs are rising, and clinical pathways (CPW) are one means to promote high-value care by standardizing care and improving outcomes without compromising cost or quality. However, providers do not always follow CPW, and our understanding of their perceptions is limited. Our objective was to examine pediatric hospital medicine (PHM) and pediatric emergency medicine (PEM) physician perspectives of CPW. Methods: We conducted semistructured, in-depth, one-on-one qualitative interviews with PHM and PEM physicians between February 2017 and August 2017. Interviews were audio-recorded, professionally transcribed, and accuracy verified. Using an inductive analytic strategy, we systematically coded the data to identify themes. Results: We interviewed 15 PHM and 15 PEM physicians. These providers identified many benefits and limitations of CPW, which positively or negatively impact resource utilization, communication, education of personnel, patients, and families, as well as practice behaviors and attitudes. Perceived benefits included (1) reduction of unnecessary utilization, (2) standardization of care, (3) improved communication, (4) education of oneself and others, and (5) confidence and validation when actions align with CPW. Limitations of CPW were (1) resource utilization for revisions, updates, and dissemination; (2) “tunnel vision” and cognitive biases; (3) loss of autonomy; (4) prescriptive medicine; (5) information overload; (6) pressure to adhere; and (7) guilt if actions do not align with CPW. Conclusions: CPW are tools with advantages and disadvantages that are used and viewed differently by providers. Such insight into how physicians perceive CPW may help to optimize hospital improvement work and enhance high-value care.

“What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

“…These findings are consistent with other studies showing that a lack of awareness of guidelines or perceived lack of evidence for measurable change represent a barrier to CP implementation [45,47,48]. Other researchers have highlighted the importance of developing educational material for clinical personnel [43], designing innovative strategies to optimize clinician education in high stress and fast-paced settings [41], and focusing on training and education as key intervention functions for enabling behaviour change [39,40].…”

“…Collaboration ensures that sites will be more motivated to achieve the goals of the CP implementation team. This finding aligns with other studies in emphasizing the importance of stakeholder engagement, including the opportunity it affords to identify early adopters or "change champions", engage senior leadership, establish consensus, and share local knowledge [41][42][43][44]. Site engagement also ensures that pertinent information about site-specific considerations are shared with the research team, such as competing priorities in the ED, changes in protocols, operational approvals, personnel changes, and local resources.…”

“…On the other hand, they are sceptical of supporting efforts to standardize clinical practices when they believe that the research is still evolving or that debates persist over the evidence. These conflicting views about the purpose and utility of a CP were also found in O'Hara and colleagues' study of pediatric hospitalists and emergency medicine physicians' perspectives of CPs [43].…”

“…They also insisted that the goals of a CP versus those of a research study should be kept distinct, explicitly defined, and clearly communicated to clinicians at the participating sites. This may help to explain some clinicians' resistance to a CP, as other studies have shown that potential barriers to implementation include differing views on the applicability of CPs or lack of awareness or communication regarding guidelines and their efficacy [43,45,46]. Thus, the goals of the CP must be clearly communicated to clinicians in terms of patient assessment and management of care, clinical flow and organization, and availability of resources.…”

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review

“…This standpoint gave legitimacy to decisions within the teams" (33) Environment demand (24,32,33,35,55,72,76) "Participants felt they had been thrown into the deep end when it came to implementation work" (33) Pride VBHC resource ( 24) "[…] participants were proud of their cooperation with the representatives as this contributed to the legitimacy of their implementation work" (24) complexity with new tasks in VBHC as a result of task expansion (60). The second study suggested information overload due to working with care pathways (73).…”