Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.
Coronary artery disease
Guideline Adherence
Small area-analysis
Standard of Care [MeSH]
Treatment pathway [non-MeSH]
Journal
BMC health services research
ISSN: 1472-6963
Titre abrégé: BMC Health Serv Res
Pays: England
ID NLM: 101088677
Informations de publication
Date de publication:
25 Apr 2024
25 Apr 2024
Historique:
received:
26
09
2023
accepted:
26
03
2024
medline:
26
4
2024
pubmed:
26
4
2024
entrez:
25
4
2024
Statut:
epublish
Résumé
The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study. General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis. Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees. Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.
Sections du résumé
BACKGROUND
BACKGROUND
The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.
METHODS
METHODS
General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.
RESULTS
RESULTS
Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.
CONCLUSIONS
CONCLUSIONS
Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.
Identifiants
pubmed: 38664649
doi: 10.1186/s12913-024-10904-5
pii: 10.1186/s12913-024-10904-5
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
527Informations de copyright
© 2024. The Author(s).
Références
Figulla HR, Lauten A, Maier LS, Sechtem U, Silber S, Thiele H. Percutaneous coronary intervention in stable coronary heart disease - is less more? Dtsch Arztebl Int. 2020;117(9):137–44.
pubmed: 32234189
Deutsche Herzstiftung e.V., editor. 32. Deutscher Herzbericht 2020: Sektorenübergreifende Versorgungsanalyse zur Kardiologie, Herzchirurgie und Kinderherzmedizin in Deutschland. Frankfurt am Main; 2021.
Frank-Tewaag J, Bleek J, Günster C, Schneider U, Horenkamp-Sonntag D, Marschall U, et al. Regional variation in coronary angiography rates: the association with supply factors and the role of indication: a spatial analysis. BMC Cardiovasc Disord. 2022;22:72.
doi: 10.1186/s12872-022-02513-z
pubmed: 35219312
pmcid: 8882285
Möckel M, Searle J, Jeschke E, Indikation. Prognose und regionale Unterschiede Der Herzkatheterversorgung in Deutschland. In: Klauber J, Günster C, Gerste B, Robra BP, Schmacke N, editors. Versorgungs-report 2013. Stuttgart: Schattauer; 2013. pp. 231–53.
Novelli A, Frank-Tewaag J, Bleek J, Günster C, Schneider U, Marschall U, et al. Identifying and investigating ambulatory care sequences before invasive coronary angiography. Med Care. 2022;60(8):602–9.
doi: 10.1097/MLR.0000000000001738
pubmed: 35700071
pmcid: 9257062
Kovacs E, Strobl R, Phillips A, Stephan AJ, Müller M, Gensichen J, et al. Systematic review and meta-analysis of the effectiveness of implementation strategies for non-communicable disease guidelines in primary health care. J Gen Intern Med. 2018;33(7):1142–54.
doi: 10.1007/s11606-018-4435-5
pubmed: 29728892
pmcid: 6025666
Doenst T, Thiele H, Haasenritter J, Wahlers T, Massberg S, Haverich A. The treatment of coronary artery disease. Dtsch Arztebl Int. 2022;119(42):716–23.
pubmed: 35912444
pmcid: 9835700
Bösner S, Becker A, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, et al. Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract. 2009;15(3):141–6.
doi: 10.3109/13814780903329528
pubmed: 19883149
Verdon F, Herzig L, Burnand B, Bischoff T, Pécoud A, Junod M, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23–24):340–7.
pubmed: 18561039
Haasenritter J, Biroga T, Keunecke C, Becker A, Donner-Banzhoff N, Dornieden K, et al. Causes of chest pain in primary care–a systematic review and meta-analysis. Croat Med J. 2015;56(5):422–30.
doi: 10.3325/cmj.2015.56.422
pubmed: 26526879
pmcid: 4655927
Bösner S, Haasenritter J, Becker A, Karatolios K, Vaucher P, Gencer B, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. Can Med Assoc J. 2010;182(12):1295–300.
doi: 10.1503/cmaj.100212
Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31.
doi: 10.1186/1741-7015-8-31
pubmed: 20507550
pmcid: 2893088
de Bleser L, Depreitere R, de Waele K, Vanhaecht K, Vlayen J, Sermeus W. Defining pathways. J Nurs Manag. 2006;14(7):553–63.
doi: 10.1111/j.1365-2934.2006.00702.x
pubmed: 17004966
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. 2016;14:35.
doi: 10.1186/s12916-016-0580-z
pubmed: 26904977
pmcid: 4765053
Ertner T, Awand T. Entwicklung Von Behandlungspfaden in Einzelschritten. In: Hellmann W, editor. Ambulante Und Sektoren übergreifende Behandlungspfade. Berlin: MWV Medizinisch Wissenschaftliche Verlagsgesellschaft mbH & Co. KG; 2009. pp. 59–78.
Campbell M. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694–6.
doi: 10.1136/bmj.321.7262.694
pubmed: 10987780
pmcid: 1118564
Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061.
doi: 10.1136/bmj.n2061
pubmed: 34593508
pmcid: 8482308
Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.
doi: 10.1136/bmj.h1258
pubmed: 25791983
pmcid: 4366184
Arzneimittelkommission der deutschen Ärzteschaft. Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, Deutsche Gesellschaft für Innere Medizin, Deutsche Gesellschaft für Kardiologie- Herz- und Kreislaufforschung e. V., Deutsche Gesellschaft für Nuklearmedizin, Deutsche Gesellschaft für Prävention und Rehabilitation von Herz- und Kreislauferkrankungen e. V., Nationale VersorgungsLeitlinie Chronische KHK - Kurzfassung, 4. Auflage; 2016.
Mey G, Mruck K, editors. Handbuch qualitative Forschung in der Psychologie. 1. Auflage. Wiesbaden: VS Verlag; 2010.
Kochinka A. Beobachtung. In: Mey G, Mruck K, editors. Handbuch qualitative Forschung in Der Psychologie. Wiesbaden: VS; 2010. pp. 449–61.
doi: 10.1007/978-3-531-92052-8_32
Kuckartz U. Mixed methods: Methodologie, Forschungsdesigns Und Analyseverfahren. Wiesbaden: Springer VS; 2014.
doi: 10.1007/978-3-531-93267-5
VERBI Software. MAXQDA, Software für qualitative Datenanalyse. Berlin: Consult. Sozialforschung GmbH; 2021.
Donner-Banzhoff N. Die ärztliche Diagnose: Erfahrung - Evidenz - Ritual. 1. Auflage. Bern: Hogrefe; 2022.
Francke AL, Smit MC, de Veer AJE, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inf Decis Mak. 2008;8:38.
doi: 10.1186/1472-6947-8-38
Winkler K, Gerlach N, Donner-Banzhoff N, Berberich A, Jung-Henrich J, Schlößler K. Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds. BMC Prim Care. 2023;24:110.
doi: 10.1186/s12875-023-02064-y
pubmed: 37131137
pmcid: 10152784
Moynihan R. Caution! Diagnosis creep. Aust Prescr. 2016;39:30–1.
doi: 10.18773/austprescr.2016.021
pubmed: 27340319
pmcid: 4917625
Djulbegovic B, Paul A. From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep. JAMA. 2011;305:2005–6.