04-simpson.qxp

Joint Commission Journal on Quality and Safety Physician-Perceived Barriers toAdopting a Critical Pathway forCommunity-Acquired Sumit R. Majumdar, M.D., M.P.H.
Scot H. Simpson, Pharm.D., M.Sc.
Thomas J. Marrie, M.D.
For two decades, organizations have developed clinical practice guidelines to help clinicians use relevant evidence when making decisions about appropriate health care.1,2 Ideally, guideline recommen- Background: A proven efficacious and evidence-
dations should be congruent with available resources based critical pathway for community-acquired pneu- and expertise. Despite the best of intentions, many monia (CAP) was implemented in six hospitals across a guidelines are not applied.3,4 There are many barriers to health service region (Edmonton, Canada). After one guideline adherence, including unawareness of the year (November 2000–November 2001), the pathway guidelines, negative attitudes toward the recommenda- had reduced average length of stay by 1 day (from 10.8 tions, complexity of the recommendations, and lack to 9.8 days, p < .001). However, great variation was of ownership.5 Addressing these barriers would be ex- observed in physician adherence to the pathway.
pected to facilitate adherence to guidelines.6–9 Methods: Physician-perceived barriers to adoption
Critical pathways provide one solution to address of the CAP pathway were identified through in-depth guideline implementation barriers by translating the rec- interviews. Data saturation was reached after 10 physi- ommendations into an organized sequence of time- cians, representing a convenience sample of those will- dependent events.10–12 Marrie et al. developed a critical ing to participate, were interviewed.
pathway for community-acquired pneumonia (CAP), Results: Self-reported adherence to the CAP pathway
which included a validated clinical prediction rule to was 75% (range 50%–100%). Qualitative analysis of the help with the admission decision, standardized and interview data indicated that comments could be grouped preprinted admission orders with evidence-based treat- into five themes: (1) limited applicability, (2) lack of flexi- ments, and decision aids for switching from intravenous bility to accommodate atypical clinical presentations, (3) to oral medications13; efficacy of the CAP pathway was perception of insufficient evidence to support recom- demonstrated in a randomized controlled trial. Given mendations, (4) local organizational barriers, and (5) this pathway's clinical success, we implemented it need for local adaptation. For example, one physician across all six acute care hospitals in our health region.
remarked that his community hospital had insufficient Capital Health (Edmonton, Alberta) is one of the staff to support collection of lab samples for all patients.
largest health service regions in Canada, providing care Discussion: Interventions to increase pathway adop-
at six hospitals for a population of one million. Four hos- tion and further improve quality of CAP care should pitals (two tertiary care hospitals and two community address the identified barriers. For example, local audit hospitals) are located within Edmonton. Two communi- and feedback of outcomes data to persuade physicians of ty hospitals are located in smaller urban settings the benefits of CAP pathways will need to be instituted.
July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety Table 1. Characteristics of Hospitals in Capital Health Region, 2000–2001*
Presenting with CAP * CAP, community-acquired pneumonia.
(populations of 15,000 and 55,000). CAP is a frequent rea- son for admission, with more than 1,500 patients admit- From November 2001 to February 2002 we conducted ted each year (Table 1, above). Implementation of the semistructured interviews with physicians from each of CAP pathway developed and tested by Marrie et al.13 was the hospitals. We chose a typical case sampling method completed in two phases. The first phase consisted of a to identify a representative sample of physicians who one-year planning phase, beginning in October 1999. An regularly admitted patients with CAP, irrespective of interdisciplinary team of physicians, nurses, dietitians, pathway use.14 Physicians who had admitted a patient respiratory therapists, and physiotherapists from each with CAP in the previous year were invited to take part hospital in the region was responsible for development in interviews and were provided with a small honorari- of a standard pathway to be used by all six hospitals.
um for participation. The honorarium amount offered to Care was taken to adapt the pathway to meet each hos- each participant remained the same during recruitment.
pital's needs and to operate within existing resources.
Pathway adherence was determined using the partici- The current pathway as shown in the Appendix (pages pant's response to the question: "Considering the ‘real- 394–395) represents several modifications to the original world' limitations of your actual practice, what pathway13 in that oral levofloxacin is the recommended proportion of your eligible patients do you think you are first-line antibiotic, and criteria for discharge as well as putting on the pathway?" This definition was not precise an oxygen algorithm, smoking cessation interventions, enough to identify physicians who may use portions of and immunization prompts are included. A team consist- the pathway. In addition, we did not link specific ing of a clinical nurse educator, a nurse champion, and a episodes of pathway nonadherence to a physician physician champion was responsible for implementation because of the regional nature of the implementation of the pathway at each hospital. Implementation began process and issues related to both patient and physician in November 2000. confidentiality. The final sample of 10 physicians inter- During the first year of experience with the pathway viewed represents a convenience sample of those willing (November 2000 to November 2001), 317 physicians admitted 1,616 patients with CAP. The average length of The Health Ethics Review Board of the University of stay before implementation (10.8 days) was reduced to 9.8 Alberta approved the study, and all participants provided days (p < 0.01) consistent with the clinical trial observa- written informed consent.
tions.13 However, only four of the six hospitals decreased Interviews were organized in iterations of five until length of stay, and about 20% of patients with CAP were we determined that subsequent interviews would be not placed on the pathway. We observed that physician unlikely to produce any new information (that is, data adherence to the pathway varied across the region. To bet- saturation).14,15 An interview guide was developed ter understand and examine physician-perceived barriers according to standard methods, and all interviews were to pathway adoption we undertook a series of personal conducted by the same person [S.H.S.]14–17 We asked interviews and report the findings in this article.
questions about the following topics: July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety Table 2. Examples of Questions from the
Discrepancies in identification of themes and use of par- ticipant remarks to support the observations were resolved by consensus.
General questions about management of community
acquired pneumonia:

■ How do you decide if a patient has pneumonia? We determined that data saturation had been reached — Are there specific symptoms or signs that you after interviewing 10 physicians (6 general practitioners and 4 specialists). Eight physicians were men. On aver- — Are there any tests (e.g., sputum samples, chest age, the physicians had practiced for 19 years (range, x-ray, blood work) that you routinely perform? 4–40 years) and carried seven inpatients (range, 2–15) at ■ What do you consider when deciding how severe a particular case of pneumonia is? Self-reported adherence to the CAP pathway was 75%, Questions about guidelines and pathways:
ranging from 50% to 100%. Data emerging from the inter- ■ Guidelines are one form of summarizing the infor- views could be categorized into five themes. Selected mation on a given topic. Have you found guidelines quotations are provided in Table 3 (page 390) to illus- that are useful to you? trate each theme.
Specific questions about the pneumonia pathway:
■ Do you know if anyone from this hospital helped
Limited Applicability develop the pathway? If so, who? A well-designed pathway should be as inclusive as ■ Could you describe for me what you think the pur- possible.2 Physicians identified two key elements that, in pose of the critical pathway is? their view, limited the CAP pathway's applicability. First, ■ Have you put someone on this pathway? four of the physicians thought that some of their own — If so: In what ways did it help? How do you patients did not qualify for the pathway. This was particu- think it could be improved? larly true for patients who came into the hospital with multiple active conditions (for example, heart failure, ■ What do you feel are flaws or weaknesses of this diabetes) who now presented with CAP. In other cases, the pathway did not meet physicians' needs because there were other factors to consider in discharge, particu- larly for patients with few social supports or who were ■ Management of CAP homeless—issues that were not covered in the pathway.
■ Attitudes (both positive and negative) towards guide- The second factor limiting applicability, expressed by eight physicians, was the belief that the pathway did not ■ Opinions regarding the Capital Health CAP pathway appear to offer any "added value" over and above their Examples of the key questions are provided in Table usual care. For instance, the pathway contains a safe and 2 (above). The interviewer encouraged participants to validated scale to help judge severity of the pneumonia;18 elaborate on issues that concerned them and also used however, six physicians indicated they relied on their prespecified probe questions when necessary.
own clinical impression more than the scale.
Interviews were audiotaped, transcribed, and reviewed for accuracy. Two of the investigators with Little Flexibility to Accommodate Atypical Clinical qualitative research experience (S.H.S., S.R.M.) reviewed transcripts independently to identify themes Guidelines and pathways have inherent limitations,2 that represented potential barriers to CAP pathway and the CAP pathway was developed with that in mind.13 adoption.15 On completion of a group of five interviews, For example, there were no mandatory orders, merely these two investigators met to compare findings recommendations. Nevertheless, eight physicians and determine if further interviews were warranted.
viewed guidelines in general, and the CAP pathway in July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety Table 3. Representative Quotations for
particular, as a recipe or cookbook. Two physicians thought that the CAP pathway represented an opportu- nity for physicians to "disconnect their brains" and "dis- courage active thought." It was apparent that the CAP ■ "(The pathway) works if your patient is the typical pathway was not considered a tool to explicate decision patient for whom it was designed, but every patient making.2 Rather, as indicated by three physicians, the pathway was perceived to be a rigid set of instructions ■ "Not everyone fits into a guideline. . I review that other health care staff followed too closely.
them but don't stick to them because each patientis different." Perception of Insufficient Scientific Evidence to ■ "Patients are coming from backgrounds that don't allow us to send them back to a loving family Support Recommendations because there is no loving family." The impact of guideline and pathway recommenda- ■ "No pathway can replace clinical experience and tions may be strengthened when supported by high- medical thinking." quality evidence.2 In the absence of such evidence, either actual or perceived, physicians are less likely to adopt Little Flexibility to Accommodate Atypical Clinical
recommendations.5,19 Three physicians indicated that they would use the pathway more if it was shown to ■ "(Staff members) were more focused on ticking shorten the hospital stay. In addition, physicians thought off all the checkboxes than actually treating thepatient. I have decreased my use of the pathway that some of the testing and treatment recommendations because I don't want people bugging me." lacked credibility. For example, although the pathway ■ "Staff should realize that we don't have to be stick- suggested routine collection of sputum, five physicians lers for everything and that there (has to be) room remarked that this was unnecessary because the results for flexibility." would not be reported in time to change their manage- ment. The pathway also suggested that all patients with- Perception of Insufficient Scientific Evidence to
Support Recommendations:

out contraindication be treated with levofloxacin, a ■ "You have to convince us that if we follow it, the proven effective agent for CAP treatment. Two physi- pathway will shorten the hospital stay." cians were not confident in that choice, either because it ■ "Some of the testing may be (more) for specialists had failed to resolve pneumonia in a previous patient, or and statisticians." because it caused adverse reactions. One physician was ■ "(Levofloxacin) is supposed to be absorbed com- skeptical of the suggestion to use oral levofloxacin pletely when taken orally, but if they are sick whenever possible.
enough to be in hospital, I put them on an intra-venous antibiotic." Organizational Issues with Implementation Organizational Issues with Implementation:
Use of guidelines and pathways can be hampered by ■ "The pathway was posited on us by Capital organizational issues such as lack of time, insufficient resources (for example, staff), and lack of funding.5,20–22 Workload-related issues such as limited time and Need for Local Adaptation:
increased paperwork were raised by six physicians. For ■ "The pathway was written with no knowledge example, two physicians indicated that the CAP pathway about community-based medicine, and therefore itapplies only to tertiary care hospitals." order pages (although preprinted to save time and effort) were either too numerous or did not provide suf- ■ "The recommendations come from an ivory tower that is out of touch with the realities of adminis- ficient space to write additional orders, especially for tering medicine in the real world." other medications.
Several pre-emptive initiatives undertaken during the planning and implementation stage of the CAP pathway July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety were not recognized or mentioned during the interviews.
pathway 75% of the time, there was a one-day decrease in One key initiative was to have local representation by length of stay after implementation of the pathway, and clinicians and staff from each hospital.23,24 These "local process-of-care indicators (for example, admission of champions" were to liaise between the health region and patients with a high pneumonia severity index, step-down physicians at each hospital so that everyone had a from intravenous to oral antibiotic therapy) improved.
chance to contribute to pathway development. However, Nevertheless, we believe that there is still room for none of the interviewed physicians recalled who his or improvement. The qualitative data reported here are fair- her local representative was nor was he or she aware ly concordant with barriers reported previously,5,25 and that each physician had an opportunity to contribute to provide us with insights and opportunities that will allow the pathway. During early introduction of the CAP path- us to further refine and improve our regional pathway.
way, most of the physicians recalled attending a grand First, involvement of the local hospital physicians rounds presentation of some type. None of the physi- needs to be a more explicit and integral part of the imple- cians recalled a more personalized, peer-to-peer dissem- mentation program.23,24 The advantages of this process ination strategy that had been planned to facilitate local were recognized early on, with involvement of local adoption. Last, although clinical evidence supporting use champions from each hospital to promote implementa- of the CAP pathway was published in a very widely read tion of the pathway. However, on the basis of our inter- general medical journal,13 none of the interviewed physi- views, the identity and role of these local representatives cians had read or even recalled the article.
were not well publicized. Indeed, none of the physicians was aware that he or she could contribute to the develop- Need for Local Adaptation ment of the pathway and therefore may not have had a Modification of a guideline or pathway to coincide sense of ownership.23,24 As part of a continuous quality with local needs is considered to be important for local improvement process, we now plan to better inform "ownership" and acceptance.2 Although local representa- physicians about opportunities to change the pathway tives were used during the planning stages of the CAP and provide greater opportunities for feedback. In par- pathway to accommodate the needs of each hospital, ticular, we need to do a better job of cultivating local two physicians told us that the pathway did not appear champions to better "market" the pathway itself.
to consider the resources available in community hospi- Although it might be a daunting task to try and actively tals. For example, one physician remarked that the path- inform all 317 of our admitting physicians about the way appeared to be designed for research and that in this pathway and its future refinements, the diffusion of inno- community hospital there were insufficient staff to sup- vations literature suggests that if we select (using previ- port collection of lab samples (blood gases, blood cul- ously validated instruments) appropriate site-specific tures, sputum samples) from every patient placed on the opinion leaders, their endorsement will facilitate further adoption of the pathway.26 In theory, only about one-fifth of physicians (n = 60) would need to be exposed to these opinion leaders and the pathway before we might start Critical pathways provide a mechanism for health care to observe an exponential increase in adoption.27 As a systems to focus on clinical outcomes while minimizing first step, one of us [S.R.M.] is currently surveying com- unnecessary practice variations.10–12 We adapted a proven munity physicians and identifying local opinion leaders and efficacious critical pathway for pneumonia13 and for a variety of acute and chronic conditions.
implemented it in all of the hospitals in our region.
Second, better education of all physicians, nurses, Despite the somewhat negative attitudes and beliefs of and other health care staff involved with the pathway is the physicians interviewed, by most conventional criteria needed.28 Some areas of perceived need were specifi- these efforts could be considered effective and success- cally identified during our interviews. Physicians and ful. For example, the pathway was implemented in all six allied health care staff who were not directly involved hospitals, physicians reported that they adhered to the in the CAP pathway development need to understand July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety the justification for some recommendations. For no mandatory steps. Overcoming this final attitude may example, the pathway recommended sputum collection be the greatest challenge we face.
as part of the standard diagnostic workup.13 This step The next steps, as just described, assume of course was based on the Canadian Community-Acquired that the pathway itself will remain fundamentally Pneumonia Working Group recommendations for unchanged. Our pathway is evidence-based and, unlike microbiological investigation.29 There are some recog- many quality improvement interventions, has actually nized advantages to using sputum samples to identify been demonstrated to be safe and efficacious in a ran- the pathogen, including selection of the optimal drug, domized controlled trial. Nevertheless, if our next steps reduction of antibiotic abuse, and identification of do not further improve adherence and processes and organisms that can have important epidemiological outcomes of care during the next cycle of measurement, implications, such as penicillin-resistant Streptococcus we will need to change core components of the pathway.
pneumoniae.29,30 However, with the exception of a Just as with drugs and devices, it may be that quality Gram stain, information obtained from a sputum sam- improvement tools that are efficacious in the controlled ple is not available until after antibiotic selection and trial setting will not be effective in the real world.
other major treatment decisions have been made.
Identification of the specific pathogen may not change treatment decisions or affect treatment outcomes.29,31 Careful attention to identifying physician-related barri- The debate over the impact of sputum samples may ers, even after relatively successful implementation of a explain the physicians' reluctance to follow this recom- new program, is an important step in the process of con- mendation routinely. If this recommendation continues tinuous quality improvement.36 We believe that we have to pose a major barrier to adoption of the pathway, it illustrated an important contribution that qualitative data may be dropped. Adherence to recommendations may might make. Providing targeted interventions to over- be improved by making the motives and evidentiary come specific physician-related barriers should result in rationale behind them more transparent.2,5,9 In addition, the wider adoption of best practices for managing the CAP pathway's positive effects on resource use and community-acquired pneumonia in our health region. J
patient outcomes need to be convincingly demon- The research reported in this article was supported by a grant from the strated to local physicians. We have data for the year Institute of Health Economics (Edmonton, Alberta). The implementa-tion and evaluation of the critical pathway itself were supported by a before and the year after the pathway was implement- grant-in-aid from the Capital Health Authority, Edmonton, Alberta,Canada, and by an establishment grant from the Alberta Heritage ed, and the local impact of the CAP pathway will be Foundation for Medical Research to Dr. Marrie. Dr. Majumdar is a evaluated and widely reported throughout the region.
Population Health Investigator supported by the Alberta HeritageFoundation for Medical Research and a New Investigator supported by We will be providing this feedback on a site-by-site the Canadian Institutes of Health Research.
basis and, perhaps, even at the level of the individual physician with comparison to local peers.32 Third, we need to address the recurring pejorative Sumit R. Majumdar, M.D., M.P.H., is Assistant Professor,
Department of Medicine, University of Alberta, Edmonton,
attitude that the CAP pathway (and guidelines in gener- Alberta. Scot H. Simpson, Pharm.D., M.Sc., is Research
al) represent "cookbook medicine."1,33–35 Although critical Associate, Institute of Health Economics, Edmonton.
pathways are management tools designed to encourage Thomas J. Marrie, M.D., is Professor and Chairman,
standardization of resource use and patient care, our Department of Medicine, University of Alberta. Please physicians were free to determine the degree to which address requests for reprints to Scot H. Simpson, pathway recommendations were appropriate for each of Pharm.D., M.Sc., ssimpson@ihe.ca.
their patients.10 Within our pathway, in fact, there were July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety 1. Battista R.N., Hodge M.J., Vineis P.: Medicine, practice and guide- 19. Rice M.S.: Clinical practice guidelines. Med J Aust 163:144–145, lines: the uneasy juncture of science and art. J Clin Epidemiol 48:875–880, Jul. 1995.
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4. Worrall G., Chaulk P., Freake D.: The effects of clinical practice 22. Stange K.C., Flocke S.A., Goodwin M.A.: Opportunistic preventive guidelines on patient outcomes in primary care: A systematic review.
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6. Oxman A.D., et al.: No magic bullets: A systematic review of 102 tri- 24. Wise C.G., Billi J.E.: A model for practice guideline adaptation and als of interventions to improve professional practice. CMAJ implementation: Empowerment of the physician. Jt Comm J Qual 153:1423–1431, Nov. 1995.
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27. Rogers E.M.: Diffusion of Innovations, 4th ed. New York: Free 10. Pearson S.D., Goulart-Fisher D., Lee T.H.: Critical pathways as a Press, 1995.
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July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety Appendix 1. Approach to a Patient with Community-Acquired Pneumonia (CAP)*
July 2004 Volume 30 Number 7 Joint Commission Journal on Quality and Safety Appendix 1. Approach to a Patient with Community-Acquired Pneumonia (CAP),* continued
* CT, computed tomography; RR, respiratory rate; O2, oxygen; BP, blood pressure; AFB, acid-fast bacillus; ABG, arterial blood gas; COPD, chronic obstructivepulmonary disease; ICU, intensive care unit; CURB, confusion, urea, respiratory rate, and blood pressure score; PSI, pneumonia severity index; ATS, AmericanThoracic Society; PO, orally; IV, intravenously.
July 2004 Volume 30 Number 7

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