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Understanding the implementation of care pathways. Process evaluation of the implementation of an evidence-based care pathway for colorectal cancer surgery in a multicenter setting.

Boek - Dissertatie

Understanding the implementation of care pathways. Process evaluation of the implementation of an evidence-based care pathway for colorectal cancer surgery in a multicenter setting Introduction During the past decades, perioperative care for patients undergoing surgery for colorectal cancer has shifted towards more standardized care, the so-called 'enhanced recovery after surgery' (ERAS). Those standardized programs aim to incorporate interventions in the perioperative care in order to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. According to recent guidelines, the ERAS program is strongly recommended. Despite growing evidence for the benefit of the implementation of such standardized programs, adherence in daily practice stays difficult. Clinicians, managers and policy makers are striving for optimal care in terms of high quality and efficiency. To achieve this, care programs such as ERAS are implemented using care pathways. Care pathways, also known as critical pathways or clinical pathways, are used worldwide as one of the tools to structure or design care processes around patients' needs and, by doing so, to improve the quality of delivered care. Care pathways can be used as a tool to improve adherence to standardized care programs. THe effect of care pathways is well studied, but little is known about the implementation process. The aim of this PhD study is twofold: (1) To perform an international quality of care improvement initiative for patients undergoing surgery for colorectal cancer, and (2) to evaluate the implementation process of a care pathway for colorectal cancer surgery by performing a process evaluation. Methods A model pathway was constructed based on a systematic literature review in three electronic data bases. Next, a retrospective patient record analysis was performed in 12 hospitals in four European countries (Belgium, France, Germany, the Netherlands) to establish a baseline. Measures used were length of stay, morbidity and mortality, and protocol adherence. Twenty consecutive patients who met the inclusion criteria (adults, scheduled surgery) were included per hospital. Following the baseline measurement, the participating teams received feedback on their performance in (1) a national feedback session and (2) in an on-site session. The local session was followed by an on-site quality improvement session in which the model care pathway was explained, focusing on local goals. After implementation, a qualitative evaluation of the implementation process was performed before the quantitative effects were known. In-depth interviews with three professionals per hospital were conducted, transcribed verbatim and analyzed using the Framework approach. The Medical Research Council guideline on process evaluation was used as thematic framework. A quantitative effect measurement was performed in 10 of the original 12 hospitals using the same methods as for the baseline measurement. Finally, a mixed methods case study was performed to evaluate the implementation from both a qualitative and quantitative perspective simultaneously. A ranking of the hospitals was made, based on the improvement rates, the high and low performing cases were included in the study. The extended Normalization Process theory was used as analytical framework. Results Fifteen studies were included in the systematic review. We identified 33 key interventions to incorporate in the model pathway. We observed considerable variation in both the number (nine to 20) and content of the interventions used in the included studies. A total of 25 indicators was found that are used to measure the effect of enhanced recovery protocols. The clinical content was summarized in the model pathway which served as basis for teams to develop or adapt their own pathway. In total, 230 patients were included in the baseline measurement. An overall median protocol adherence of 44% was measured, but with high variability between and within the hospitals. Only six interventions scored "important and high performant" in the importance-performance analysis. In-depth interviews with 32 direct involved healthcare professionals were conducted before quantitative results were known. We used the Framework approach to analyze the data. Based on the perceived outcomes, respondents were divided in two subgroups: those perceiving positive outcomes and those perceiving no effect. For each group the factors explaining the implementation process were mapped in the categories from the MRC guidance: intervention (the evidence base of the care pathway), context (prolonged involvement of multiple disciplines, availability of a clinical data system), implementation (several implementation activities, focusing on competence, behavior, or workplace), and mechanisms (teamwork and collaboration). The use of feedback is perceived as an important implementation activity used for goal-setting and motivation. In total, 191 patients were included in the effect measurement, resulting in a total of 381 patients from 10 hospitals (190 vs 191). Length of stay decreased significantly from 12.6 to 10.7 days (p=0.0230), while mortality, readmission and re-intervention rates did not change. Overall protocol adherence improved from 56 to 62% (p<0.00001). Across hospitals, change in overall protocol adherence ranged from a 13% decrease to a 22% increase. Only in 25% of patients a protocol adherence of ≥70% was achieved, suggesting a large proportion of patients is at risk for underuse. From the ranking of the hospitals, two were identified as high performance cases, and three as low performance cases, and three as low performance cases and these cases were compared to each other. Factors that could explain the differences in pre- and post-implementation performance were: the level of integration of the care pathway, the experience and support of the improvement team in care pathway methodology, the motivation of the team, shared goals, level of management support and alignment of care pathway development and hospital strategy, and finally the cognitive participation of relevant disciplines, most noticeably the physician. Conclusion Overall, we concluded that this international quality improvement initiative was successful in reducing mean length of stay with almost two days. Protocol adherence improved overall to a median of 62%, with great variability between the hospitals. These outcomes are statistically significant, but can be considered modest. Despite the improved protocol adherence, our results suggest that a large proportion of patients is still at risk for under-use of care. We propose a model for the implementation of care pathways. The implementation and normalization of care pathways asks for the contribution of multiple involved professionals at organizational, team and individual level. Both the capability of the care pathway as well as the context, described in terms of potential (to follow care pathway methodology) and capacity (to cooperate and coordinate actions) influence the implementation and vice versa. But it is contribution that leads to outcomes: success of care pathway implementation depends on the activities people do to implement it.
Jaar van publicatie:2019