Beyond Awareness: A Qualitative Assessment of Barriers and Facilitators to Implementing Metabolic Dysfunction–Associated Steatotic Liver Disease Care Pathways in Primary Care

Background and Aims: Health-care systems must adapt to a rising burden of metabolic dysfunction-associated steatotic liver disease (MASLD), yet implementation in primary care remains challenging. While existing strategies often target knowledge deficits, our study uniquely examines how cognitive, contextual, and experiential factors shape general practitioners' (GPs) decision-making. This qualitative study explores GPs' experiences with MASLD care and previous care innovations to identify barriers and facilitators to implementing MASLD care pathways in primary care. Methods: We conducted semistructured interviews with 15 Dutch GPs from diverse backgrounds, enhancing data richness through cointerviewing. Guided by an interpretivist approach, we applied inductive thematic analysis per Braun and Clarke. Maximum variation sampling was applied, and interviewing continued until sufficient information power was achieved for analytic sufficiency. Results: Findings were organized using a sliding scale framework: 1 consistent theme promoting innovation and 3 dynamic themes that can facilitate or impair innovation. GPs expressed strong intrinsic motivation for innovations, rooted in patient-centeredness and lifelong learning, yet continuously weighed this against identity-related, relational, and practical considerations. GPs stressed that primary care is not merely hospital care at a different place. They evaluate innovations pragmatically through a Bayesian lens, considering prior disease probability, test performance, and feasibility, combined with assessment of individual patient benefit. Key barriers included low perceived urgency for MASLD, driven by limited experiential knowledge and skepticism toward specialist-derived evidence. GPs perceived trust-based partnerships, organizational continuity, and contextual fit as critical. Conclusion: Implementing hepatology-derived innovations in primary care is complex and extends beyond financial incentives or educational interventions. Effective strategies require codesigned, context-sensitive, and practice-integrated approaches that align with GPs' distinct logic and perspectives, including of those less engaged with MASLD.