title: Qualitative evaluation of a local coronary heart disease treatment pathway: practical implications and theoretical framework.
abstract: BACKGROUND
  Coronary heart disease (CHD) is a common medical problem in general practice. Due to its chronic character, shared care of the patient between general practitioner (GP) and cardiologist (C) is required. In order to improve the cooperation between both medical specialists for patients with CHD, a local treatment pathway was developed. The objective of this study was first to evaluate GPs' opinions regarding the pathway and its practical implications, and secondly to suggest a theoretical framework of the findings by feeding the identified key factors influencing the pathway implementation into a multi-dimensional model.
  
  
  METHODS
  The evaluation of the pathway was conducted in a qualitative design on a sample of 12 pathway developers (8 GPs and 4 cardiologists) and 4 pathway users (GPs). Face-to face interviews, which were aligned with previously conducted studies of the department and assumptions of the theory of planned behaviour (TPB), were performed following a semi-structured interview guideline. These were audio-taped, transcribed verbatim, coded, and analyzed according to the standards of qualitative content analysis.
  
  
  RESULTS
  We identified 10 frequently mentioned key factors having an impact on the implementation success of the CHD treatment pathway. We thereby differentiated between pathway related (pathway content, effort, individual flexibility, ownership), behaviour related (previous behaviour, support), interaction related (patient, shared care/colleagues), and system related factors (context, health care system). The overall evaluation of the CHD pathway was positive, but did not automatically lead to a change of clinical behaviour as some GPs felt to have already acted as the pathway recommends.
  
  
  CONCLUSIONS
  By providing an account of our experience creating and implementing an intersectoral care pathway for CHD, this study contributes to our knowledge of factors that may influence physicians' decisions regarding the use of a local treatment pathway. An improved adaptation of the pathway in daily practice might be best achieved by a combined implementation strategy addressing internal and external factors. A simple, direct adaptation regards the design of the pathway material (e.g. layout, PC version), or the embedding of the pathway in another programme, like a Disease Management Programme (DMP). In addition to these practical implications, we propose a theoretical framework to understand the key factors' influence on the pathway implementation, with the identified factors along the microlevel (pathway related factors), the mesolevel (interaction related factors), and system- related factors along the macrolevel.
authors.affiliation: Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Straße 4, 35043, Marburg, Germany. lena.kramer@staff.uni-marburg.de
authors.forename: Lena
authors.initials: L
authors.lastname: Kramer
authors.forename: Kathrin
authors.initials: K
authors.lastname: Schlößler
authors.forename: Susanne
authors.initials: S
authors.lastname: Träger
authors.forename: Norbert
authors.initials: N
authors.lastname: Donner-Banzhoff
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D034201:Computers, Handheld; D003327:Coronary Disease / Q000628:therapy*; D019091:Critical Pathways; D005260:Female; D005858:Germany; D006123:Group Practice / Q000706:statistics & numerical data; D019983:Guideline Adherence; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D018670:Monitoring, Ambulatory; D010821:Physicians, Family / Q000523:psychology* / Q000706:statistics & numerical data; D011331:Private Practice / Q000706:statistics & numerical data; D011365:Professional Practice Location / Q000706:statistics & numerical data; D036301:Qualitative Research