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Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care.

ABSTRACT: AIM:To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care. DESIGN AND PROCEDURE:Mixed-measures design. Quantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software. SETTING:The first HealthPathways UK site, South Tyneside, England. PARTICIPANTS:General practitioners, nurses, practice managers, hospital consultants and system leaders (managers, commissioners) (n=76). RESULTS:Use of the pathways significantly increased over time. Themes were developed showing how online care pathways were used-leadership, pre-existing networks and relationships; development of systems and processes for care pathways, the use of online care pathways to support decision-making and referral, and perceived availability of resources. Inter-related themes were arranged into configurations consisting of contextual influences, mechanisms and outcomes. Recommendations were made for future implementations, such as improved data collection processes to understand how and why there was variance in the use of pathways. CONCLUSIONS:This study was early in the implementation process; however, emerging themes will facilitate the future implementation and use of online care pathways. Recommendations are made for further research to include other health and social care users and patients to inform future developments.

SUBMITTER: Akehurst J

PROVIDER: S-EPMC6318508 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care.

Akehurst Joy J Sattar Zeibeda Z Gordon Isabel I Ling Jonathan J

BMJ open 20181231 12

<h4>Aim</h4>To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care.<h4>Design and procedure</h4>Mixed-measures design. <i>Q</i>uantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software.<h4>Setting</h4>The first HealthPathways ...[more]

PMID: 30598485

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Project description:BackgroundA high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients' home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.MethodsOne hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients' medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.ResultsMean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.ConclusionsThis mixed-methods process evaluation provided novel insights into practitioners' decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients' readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.Trial registration( ISRCTN13790648 ). Registered 14 May 2015.

Project description:OBJECTIVES:To examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved. DESIGN:Mixed-method evaluation of a primary care e-consultation system. SETTING:Primary care practices in South West England. METHODS:Qualitative interviews with 23 practice staff in six practices. Patient survey data for 756 e-consultations from 36 practices, with free-text survey comments from 512 patients, were analysed thematically. Anonymised patients' records were abstracted for 485 e-consultations from eight practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and the usage of the e-consultation system were informed by: (1) normalisation process theory, (2) a framework that illustrates how e-consultations were co-produced and (3) patients' and staff touchpoints. RESULTS:We found different expectations between patients and staff on how to use e-consultations 'appropriately'. While some patients used the system to try and save time for themselves and their general practitioners (GPs), some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation. CONCLUSIONS:Where both patients and staff interact with technology, it is in effect 'co-implemented'. How patients used e-consultations impacted on practice staff's experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.

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Dataset Information

Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care.

Publications

Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care.

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