title: Main barriers to effective implementation of stroke care pathways in France: a qualitative study.
abstract: BACKGROUND
  Stroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France.
  
  
  METHODS
  We selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals.
  
  
  RESULTS
  Four main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care.
  
  
  CONCLUSIONS
  Lack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.
authors.forename: Kristel
authors.initials: K
authors.lastname: Gache
authors.forename: Henri
authors.initials: H
authors.lastname: Leleu
authors.affiliation: Compaq-HPST, Institut de Cancérologie Gustave Roussy, 114 rue Edouard Vaillant, Villejuif 94805, France. gerard.nitenberg@igr.fr.
authors.forename: Gérard
authors.initials: G
authors.lastname: Nitenberg
authors.forename: France
authors.initials: F
authors.lastname: Woimant
authors.forename: Marie
authors.initials: M
authors.lastname: Ferrua
authors.forename: Etienne
authors.initials: E
authors.lastname: Minvielle
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration; D019091:Critical Pathways / Q000458:organization & administration*; D005602:France / Q000453:epidemiology; D006266:Health Education; D006282:Health Personnel; D006295:Health Resources / Q000600:supply & distribution; D006801:Humans; D007407:Interviews as Topic; D016730:Program Development; D036301:Qualitative Research; D011787:Quality of Health Care / Q000458:organization & administration; D020521:Stroke / Q000628:therapy*