Facilitators and Barriers to the Implementation of the Primary Care Asthma Paediatric Pathway: A Qualitative Analysis

ObjectiveThe Primary Care Asthma Paediatric Pathway (PCAPP) included an EMR embedded pathway that provided an evidence-based approach to paediatric asthma management. The aim of this qualitative study was to use a theory-based approach to understand the facilitators and barriers that impacted the implementation of the PCAPP in primary care.Methodsa randomized cluster-controlled design was implemented in 22 primary care practices in Alberta, Canada with half receiving the PCAPP intervention and the other half receiving usual care. Following the implementation of the complex intervention, a purposeful sample of intervention sites were selected to participate in qualitative focus groups to assess the barriers and facilitators to the implementation.ResultsOur qualitative findings are organized into three themes using the core constructs of the normalization process theory (NPT): (1) facilitators of implementation, (2) barriers to implementation, and (3) proposed mitigation strategies. Participants were positive about the pathway, and felt it served as a reminder of optimal paediatric guideline-based asthma management, a streamlined pathway multi-faceted approach to suggest evidence-based care, and an EMR-based targeted collection of tools and resources. Barriers included a generally low priority for the primary care teams, and, in accordance, clinicians suggested they had few children with asthma in their practices. The pathway was not integrated into clinic flow and there was not a specific process to ensure the pathway was used. Sites without project champions also struggled more with implementation. Despite these barriers, clinicians identified clear mitigation strategies to improve uptake including developing a reminder system within the EMR and creating a work-flow that incorporated the pathway.ConclusionOur study demonstrated the applicability of the NPT in the implementation of an evidence-based pathway for primary care. This study demonstrated it is important to ensure teams participate in enrolment (establishing buy-in), legitimization (ensuring teams see their role in the pathway) and activation (an ongoing plan for sustainability). Had these components of cognitive participation been addressed more carefully prior to implementation there may have been greater uptake, and ongoing use of the pathway. Trial Registration: This study was registered at clinicaltrials.gov on June 25, 2015; the registration number is: NCT02481037, https://clinicaltrials.gov/ct2/show/NCT02481037?term=andrew+cave&cond=Asthma+in+Children&cntry=CA&city=Edmonton&draw=2&rank=1