Despite the declining mortality of patients in recent years with coronary heart disease (CHD) in Western countries [
1,
2], CHD remains the leading cause of morbidity and mortality in adults worldwide [
3]. In the United States, about 7.0 % (women) to 9.1 % (men) of the general population are affected by CHD [
4]. Similar prevalence rates (women: 6.5 %, men: 9.2 %) have been found in Germany [
5]. Most patients with CHD need lifelong, continuous, complex medical care, which is extremely costly to the healthcare system [
6].
In this context, an important role is attached to the shared care of patients with CHD by the general practitioner (GP) and the cardiologist. Better coordination and communication between GP and medical specialist promises optimized medical treatment along with increased cost-effectiveness in primary care [
7‐
9]. Improving the cooperation between different health care professionals and providing optimal evidence-based medical care for patients are the main objectives of clinical guidelines [
10]. For CHD, it was demonstrated that non-adherence to medical recommendations is associated with a broad range of adverse outcomes in patients [
11]. Despite the high scientific quality of most guidelines and their wide promulgation, their actual impact on clinical practice and quality of care is limited [
12‐
15]. Numerous international studies have shown that effective and lasting behaviour change of health care professionals is difficult to achieve and is influenced by multiple factors [
16‐
18]. Although guidelines may be seen as necessary to provide valid recommendations, they are insufficient in ensuring evidence-based decision-making [
19]. In this context, the use of clinical pathways as one approach to facilitate the adaption of research findings in daily practice is important. Clinical pathways are multidisciplinary, locally translatable, and involve a stepwise procedure, determined timeframes, and standardized care for a specific clinical problem [
20]. Even though the implementation of clinical pathways faces similar problems as the implementation of guidelines [
21,
22], some authors [
19,
23,
24] expect treatment pathways to raise implementation chances by adapting the guideline recommendations to local conditions and thereby referring more to physicians’ work reality. However, the effect of local treatment pathways is controversial, as Salegy and colleagues [
25] rarely found an implementation benefit by the local adaption. Additionally, the local adaption was associated with higher costs compared to national guidelines. Nevertheless, the development and use of a local pathway might be appropriate in situations where an additional advantage is expected by its use. This might be of importance if system related factors require local adjustments [
25].
To date, most experience with treatment pathways is gained in countries with a Beveridge type of health care system, characterized by a strong governmental influence. In countries like Germany, where a Bismarck type of health care system is established [
26], the implementation of shared care pathways poses a special challenge as they are less regulated by institutional standards. Patients have universal medical access with only a very limited gate-keeping role of the GP. Due to the system structure, competition between medical professionals in the ambulatory sector (primary and secondary care) hinders cooperation. Thus, despite a greater need for coordination, the establishment of shared care pathways is paradoxically much more difficult to achieve in Bismarck types of health care systems. By developing and implementing a shared care pathway for patients with CHD in a Bismarck type system, we intended to close this gap and contribute a new aspect to existing research primarily made in the Beveridge type of health care systems.
Within this context of developing and evaluating a local CHD pathway we pursued two objectives in this study. On the one hand we aimed to evaluate GPs’ opinion regarding the pathway and give practical implications for clinical practice that derived from this evaluation. On the other hand we strived to abstract our findings by putting the identified key factors influencing the pathway implementation into a multi-dimensional model.