From ideal to actual practice: Tailoring a clinical pathway to address anxiety or depression in patients with cancer and planning its implementation across individual clinical services

Introduction: Clinical pathways (CPs) can improve health outcomes, but evidence of their impact is mixed, perhaps due to variations in CP delivery. Identifying why variations occur, and their intended purpose is important, to guide CP development and implementation. We developed a CP for screening, assessment and management of anxiety and depression in cancer patients (the ADAPT CP). The CP was implemented in 12 Oncology services in Australia that were participating in the ADAPT Cluster randomized controlled trial (CRCT), allowing some tailoring of the CP for local conditions. The aim of this article is to describe what and why decisions were made to tailor the ADAPT CP in these services. Method: Twelve oncology services were purposively selected for diversity in setting. At each service, a multi-disciplinary lead team was formed to make decisions about local tailoring and to plan, champion and enact the CP implementation. Detailed notes taken during engagement meetings, and service-specific workflow diagrams, form the data for this analysis. Notes were content-analyzed, and workflows reviewed, to identify decision-making themes. Results: Twelve cancer services (7 urban and 5 regional) participated in CRCT. Ten were publicly funded, one was privately funded and the other was a mixed public and private service. Diverse decisions were made regarding the selection of eligible patient cohorts, how to introduce screening to patients, and screening and triage processes. Rationales for decisions included aligning with existing workflows, utilizing staff with required skills, minimizing staff burden, ensuring no patient was missed, and minimizing patient distress. Discussion: Practical issues and staff attitudes and skills often guided CP decisions, highlighting the need to work collaboratively with health services to determine the optimal workflow for each setting. In some settings, considerable discussion and problem-solving was required before processes could be agreed upon that overcame perceived barriers and allowed the CP implementation to proceed. Although it is yet to be determined whether some decisions were optimal in terms of patient outcomes, local tailoring ensured the CP became operational at all services. Allowing time and ensuring the right people are involved are essential when tailoring new CPs before their introduction into clinical care.