title: System barriers to the evidence-based care of acute coronary syndrome patients in China: qualitative analysis.
abstract: BACKGROUND
  Organizational and wider health system factors influence the implementation and success of interventions. Clinical Pathways in Acute Coronary Syndromes 2 is a cluster randomized trial of a clinical pathway-based intervention to improve acute coronary syndrome care in hospitals in China. We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China.
  
  
  RESULTS
  A qualitative descriptive analysis of 40 in-depth interviews with health professionals conducted in a sample of 10 hospitals purposively selected to explore barriers to implementation of the intervention. Qualitative data were analyzed using the Framework method. In-depth interviews identified 5 key system-level barriers to effective implementation: (1) leadership support for implementing quality improvement, (2) variation in the capacity of clinical services and quality improvement resources, (3) fears of patient disputes and litigation, (4) healthcare funding constraints and high out-of-pocket expenses, and (5) patient-related factors.
  
  
  CONCLUSIONS
  System-level barriers affect the ability of acute coronary syndrome clinical pathways to change practice. Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of acute coronary syndromes, and potentially other hospitalized conditions, in China. Clinical Trial Registration- URL: http://www.anzctr.org.au/default.aspx. Register. Unique identifier: ACTRN12609000491268.
authors.affiliation: Cardiovascular Division, George Institute for Global Health, University of Sydney, Sydney, Australia.
authors.forename: Isuru
authors.initials: I
authors.lastname: Ranasinghe
authors.forename: Ye
authors.initials: Y
authors.lastname: Rong
authors.forename: Xin
authors.initials: X
authors.lastname: Du
authors.forename: Yangfang
authors.initials: Y
authors.lastname: Wang
authors.forename: Runlin
authors.initials: R
authors.lastname: Gao
authors.forename: Anushka
authors.initials: A
authors.lastname: Patel
authors.forename: Yangfeng
authors.initials: Y
authors.lastname: Wu
authors.forename: Rick
authors.initials: R
authors.lastname: Iedema
authors.forename: Zhixin
authors.initials: Z
authors.lastname: Hao
authors.forename: Dayi
authors.initials: D
authors.lastname: Hu
authors.forename: Fiona
authors.initials: F
authors.lastname: Turnbull
mesh_terms: D054058:Acute Coronary Syndrome / Q000191:economics / Q000453:epidemiology* / Q000628:therapy*; D000328:Adult; D002681:China; D017281:Cost of Illness; D003695:Delivery of Health Care / Q000458:organization & administration*; D055317:Evidence-Based Practice; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007857:Leadership; D016365:Liability, Legal; D008297:Male; D008875:Middle Aged; D009934:Organization and Administration; D010564:Personnel, Hospital; D036301:Qualitative Research; D058996:Quality Improvement / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D055502:Secondary Prevention / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: acute coronary syndrome; quality of health care