Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.

Publisher: BioMed Central Country of Publication: England NLM ID: 101088677 Publication Model: Electronic Cited Medium: Internet ISSN: 1472-6963 (Electronic) Linking ISSN: 14726963 NLM ISO Abbreviation: BMC Health Serv Res Subsets: MEDLINE

Original Publication: London : BioMed Central, [2001-

Critical Pathways* ; Coronary Angiography* ; Qualitative Research* ; Guideline Adherence*/statistics & numerical data; Humans ; Germany ; Interviews as Topic ; Male ; Female ; Coronary Disease/therapy ; Coronary Disease/diagnostic imaging ; Practice Guidelines as Topic

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: 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: 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: 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.
(© 2024. The Author(s).)

BMC Med Inform Decis Mak. 2008 Sep 12;8:38. (PMID: 18789150)
Croat Med J. 2015 Oct;56(5):422-30. (PMID: 26526879)
Aust Prescr. 2016 Apr;39(2):30-1. (PMID: 27340319)
J Nurs Manag. 2006 Oct;14(7):553-63. (PMID: 17004966)
BMC Med. 2016 Feb 23;14:35. (PMID: 26904977)
JAMA. 2011 May 18;305(19):2005-6. (PMID: 21586716)
BMC Prim Care. 2023 May 2;24(1):110. (PMID: 37131137)
Med Care. 2022 Aug 1;60(8):602-609. (PMID: 35700071)
BMC Cardiovasc Disord. 2022 Feb 26;22(1):72. (PMID: 35219312)
BMC Med. 2010 May 27;8:31. (PMID: 20507550)
BMJ. 2000 Sep 16;321(7262):694-6. (PMID: 10987780)
Swiss Med Wkly. 2008 Jun 14;138(23-24):340-7. (PMID: 18561039)
Dtsch Arztebl Int. 2022 Oct 21;119(42):716-723. (PMID: 35912444)
CMAJ. 2010 Sep 7;182(12):1295-300. (PMID: 20603345)
BMJ. 2015 Mar 19;350:h1258. (PMID: 25791983)
J Gen Intern Med. 2018 Jul;33(7):1142-1154. (PMID: 29728892)
Eur J Gen Pract. 2009;15(3):141-6. (PMID: 19883149)
BMJ. 2021 Sep 30;374:n2061. (PMID: 34593508)
Dtsch Arztebl Int. 2020 Feb 28;117(9):137-144. (PMID: 32234189)

Keywords: Coronary artery disease; Guideline Adherence; Small area-analysis; Standard of Care [MeSH]; Treatment pathway [non-MeSH]

Date Created: 20240425 Date Completed: 20240426 Latest Revision: 20240428

20240428

PMC11046897

10.1186/s12913-024-10904-5

38664649