An evaluation of the best practices and barriers for the Nagasaki acute myocardial infarction secondary prevention clinical pathway

The Nagasaki Acute Myocardial Infarction Secondary Prevention Clinical Pathway (NASP), a guideline-based regional clinical pathway, was developed to manage low-density lipoprotein cholesterol levels for patients with acute myocardial infarction (AMI) in the Nagasaki prefecture in Japan. This study aimed to summarize the perceived best practices and barriers for the dissemination and operation of the NASP. This exploratory sequential mixed methods study was developed around the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Focus group interviews were conducted with 24 physicians with experience treating AMI in alignment with the NASP at foundation hospitals. The identified themes and insights were integrated into the development of the questionnaire. The web-based, self-administered questionnaire with a cross-sectional study design was given to 62 physicians in the Nagasaki prefecture. Mixed-method data integration of the results from both study phases was conducted through meta-inferences made from the qualitative and quantitative data. The best practices included the development of multi-disciplinary operation teams at medical facilities in preparation for the implementation of the NASP, the simplification of the document preparation process, and the establishment of an additional medical fees policy for the utilization of the NASP instead of patient referral documents. Practices tailored to the type of medical institute such as instructing patients on the NASP regimen during index hospitalization for acute-care hospitals, and the development of NASP instructions and manuals for primary care hospitals/outpatient clinics were also recommended. In addition, barriers to the implementation of the NASP such as missed eligible AMI patients for the NASP and the inconsistent implementation to eligible AMI patients were identified. This study identified the perceived best practices and barriers for the NASP. This knowledge should be considered when expanding the NASP to other institutions across Japan.

长崎县急性心肌梗死二级预防临床路径（Nagasaki Acute Myocardial Infarction Secondary Prevention Clinical Pathway, NASP）是一套基于指南的区域性临床路径，旨在管理日本长崎县内急性心肌梗死（Acute Myocardial Infarction, AMI）患者的低密度脂蛋白胆固醇（low-density lipoprotein cholesterol）水平。本研究旨在总结该路径推广与运行过程中公认的最佳实践及阻碍因素。本研究采用探索性序贯混合方法设计，以RE-AIM（Reach, Effectiveness, Adoption, Implementation, Maintenance）框架为研究基础。研究团队对24名曾在基层医院按照NASP方案治疗急性心肌梗死的医师开展焦点小组访谈，将访谈提炼出的主题与见解整合至调查问卷的编制环节。本研究采用横断面研究设计，面向长崎县内62名医师发放线上自主填写式调查问卷。研究通过对定性与定量数据开展元推断，完成了两个研究阶段的混合方法数据整合分析。本次研究总结的最佳实践包括：在医疗机构组建多学科运行团队以筹备NASP的落地实施；简化文件编制流程；制定针对NASP使用的专项医疗收费政策，以替代原有的患者转诊文件要求。此外，研究还提出了针对不同医疗机构类型的定制化实践方案：对于急诊医院，需在患者首次住院期间向其讲解NASP治疗方案；对于基层医院/门诊诊所，则需编制NASP使用指南与操作手册。同时，研究也明确了NASP落地实施过程中的阻碍因素：包括遗漏符合条件的急性心肌梗死患者纳入NASP管理，以及对符合条件的患者执行NASP方案存在不一致性。本研究明确了长崎县NASP的公认最佳实践与实施阻碍因素，该研究结论可为日本全国范围内推广该临床路径提供参考依据。