Table 5 Identified Themes and Subthemes and the proportion of clinicians reporting each subtheme
Included studies | O'Brien (2016) [54] | Shelton (2019) [55] | Otte (2017) [53] | Brouwers (2014) [56] | Bristow (2018) [57] | Brown (2016) [58] | Carrick (1998) [59] | Fonteyne (2018) [60] | Gattellari (2001) [61] | Graham (2007) [15] | Grilli (1991) [62] | Ismaila (2018) [63] | Jagsi (2014) [64] | Ward (1997) [65] | White (2010) [66] |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Qualitative methods | âś“ | âś“ | âś“ | âś“ | |||||||||||
Quantitative methods | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | ||
Cancer Stream | Breast | Colon | Pancreatic | NSCLC | Prostate | Prostate | Breast | MIBC | CRC | Cancer | Breast, CRC, ovarian | Cancer | Breast | Breast | Breast |
Theme 1 Barriers: concern over CPG content and currency of CPGs | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | |||||
Some CPG recommendations are biased | âś“ | ||||||||||||||
CPG are not always applicable to specific settings or feasible | 25% | âś“ | |||||||||||||
CPGs are not always clear | âś“ | 25% | |||||||||||||
CPGs can be hard to read | 17% | ||||||||||||||
Outdated CPGs, or slow to be updated | âś“ | 31% | 6% | ||||||||||||
Some CPGs are perceived to be cookbook medicine that oversimplifies difficult or controversial treatment decisions | âś“ | 28% | 46% | 45% | 13% | 24% | 26% | ||||||||
Some CPGs are too complicated or complex to follow | âś“ | 23% | |||||||||||||
Some CPGs are too rigid to apply to practice | âś“ | 31% | 7% | 20% | |||||||||||
CPGs do not always take into account patient preferences or circumstances | 18% | 37% | |||||||||||||
Concerned that some CPGs were developed by people who were not engaged with clinical practice | 6% | ||||||||||||||
Concerned that CPGs are intended to cut costs | 12% | 17% | |||||||||||||
Theme 2 Barriers: concern about the evidence underpinning CPGs | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | |||||
CPGs underpinned by controversial evidence or a lack of evidence | âś“ | âś“ | 30% | ||||||||||||
Clinical trial patient populations that does not contain patients that clinicians routinely see | âś“ | 60% | |||||||||||||
The existence of contradicting CPGs or CPGs that provide contradicting or controversial recommendations or advice | âś“ | 16% | 10% | ||||||||||||
Some clinicians prefer their own interpretation of the evidence over the synthesis of evidence in particular CPGs | 30% | ||||||||||||||
CPGs do not always take into account clinical experience | 36% | 10% | |||||||||||||
Theme 3 Barriers: clinician uncertainty and negative perceptions towards CPGs | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | ||||
Clinical equipoise and practice habits that differ to the CPG recommendations | âś“ | âś“ | 3% | ||||||||||||
Concerns about side effects associated with CPG recommendations or past experience of patient adverse effects from CPG recommended treatments | âś“ | 3% | 25% | 10% | |||||||||||
Limited medical expertise to implement the CPG recommendation | 10% | ||||||||||||||
Clinician subjectivity’ regarding specific treatments and a perception that the CPG recommended treatments are not necessarily appropriate for specific patients | ✓ | ✓ | |||||||||||||
A lack of awareness of CPGs | 12% | âś“ | |||||||||||||
CPGs challenged clinician authority or autonomy | 15% | 8.5% | 20% | ||||||||||||
Some CPGs limit the application of clinical judgement | 18% | ||||||||||||||
Clinicians disagreeing with specific CPG recommendations | âś“ | 2% | |||||||||||||
Limited experience with CPG recommended treatments | 14% | ||||||||||||||
A lack of outcome expectation of the CPG recommendations | 67% | 70% | 10% | ||||||||||||
Concerned that CPGs will expose them to litigation issues | 37% | 33% | 45% | ||||||||||||
Theme 4 Barriers: organizational and patient factors | âś“ | âś“ | âś“ | âś“ | âś“ | ||||||||||
Limited access to treatment services | âś“ | âś“ | |||||||||||||
Treatment referral processes that are slow | 31% | ||||||||||||||
Referral processes that are unreliable | 10% | ||||||||||||||
Referral processes that are complex | 12% | ||||||||||||||
Surgeons’ hesitancy to refer patients to other clinicians | 13% | ||||||||||||||
A lack of support from organizational and clinical leadership | 32% | ||||||||||||||
CPG recommendations are not always cost effective | 8% | ||||||||||||||
Patient preferences regarding treatment choice | ✓ | ✓ | < 1% | ||||||||||||
Patient comorbidities and tumor specific characteristics | âś“ | ||||||||||||||
The level of family support available to patients, and access to transport influences the treatment provided | âś“ | ||||||||||||||
family perceptions of or experiences of treatments were found to influence patient attitudes | âś“ | ||||||||||||||
The age of the patient | âś“ | ||||||||||||||
Concerns about costs of treatments or concern that adhering to CPG will increase healthcare costs, and other external barriers | 61% | 18% | |||||||||||||
Poor accessibility to CPGs | 22% | âś“ | |||||||||||||
Theme 5 Facilitators: CPG accessibility and ease of use | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | ||||||||
Having highly skilled clinicians with adequate expertise to implement the CPG is important | âś“ | ||||||||||||||
CPGs should be treated as guides, not rules, to cater to individual patient needs | âś“ | ||||||||||||||
Some CPGs are considered good summaries of up-to-date evidence | âś“ | 97% | |||||||||||||
Clinicians felt it was important that CPGs were updated regularly | âś“ | ||||||||||||||
Some CPGs are considered easy to understand | 96% | ||||||||||||||
Some CPGs are considered flexible | 67% | ||||||||||||||
Some CPGs are considered implementable | 87% | ||||||||||||||
User-friendly formats were considered a strength of CPGs | 83% | ||||||||||||||
Some CPGs are developed in a timely manner | 46% | ||||||||||||||
Adapting and revising CPGs to cater for local needs, and holding meetings about the revised CPG was an important factor | 63% | 16% | 76% | ||||||||||||
Access to and availability of IT technology that integrates CPGs into the software used to record and order treatments, and provides feedback to clinicians is important | 50% | ||||||||||||||
Theme 6 Facilitators: endorsement and dissemination of CPGs along with adequate resources | âś“ | âś“ | âś“ | âś“ | âś“ | ||||||||||
Clinician and clinical organizational support is important | âś“ | ||||||||||||||
Collaboration between clinical disciplines in Multi-Disciplinary Teams (MDTs) is important | âś“ | ||||||||||||||
Easy access to treatment services for patients is important | âś“ | ||||||||||||||
CPG dissemination via medical college programs is important | 84% | ||||||||||||||
CPG endorsement by government research organizations is important | 83% | ||||||||||||||
CPG endorsement by medical colleges is important | 74% | 86% | |||||||||||||
Recommendations by respected peers, or discussions with respected peers is important | 51% | 71% | |||||||||||||
Symposia about CPGs are important | 47% | 74% | |||||||||||||
Provision of emails or websites that summarized updated CPGs, or current clinical trials underpinning CPGs are important | 54% | ||||||||||||||
Access to treatment facilities and adequate resources to implement CPGs is important | 46% | 22% | |||||||||||||
Audits and feedback are important | 54% | ||||||||||||||
Multidisciplinary clinical care pathways or MDT discussions increase awareness of CPGs | 52% | 47% | |||||||||||||
Theme 7 Facilitators: awareness of CPGs and belief in their relevance | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | |
High clinician awareness of CPGs | âś“ | âś“ | âś“ | 49-82% | 54% | âś“ | 86% | 83% | 44-60% | âś“ | 74% | 80% | 76% | ||
Agreement with and support for CPG recommendations | âś“ | âś“ | 40-93% | 71% | 49% | ||||||||||
Confidence in CPGs was high when the guidelines were considered high quality | 85% | ||||||||||||||
Use of or compliance with CPGs was generally reported to be high | âś“ | âś“ | 78% | 5-68% | 55% | 44% | 93% | 24-48% | 39% | ||||||
CPGs should be “developed by credible individuals” and include lists of CPG committee members should be published | 93% | 75% | |||||||||||||
Financial disincentives for surgeons who do not follow the guidelines | 38% | ||||||||||||||
Theme 8 Facilitators: CPGs support decision making, improve patient care, reduce clinical variation and reduce costs | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | âś“ | |||||
CPS are good, convenient sources of advice or information with unambiguous recommendations | âś“ | 89% | 79% | 94% | 98% | 88% | |||||||||
CPS are considered to be good, useful and educational tools for making treatment decisions that help clinicians orientate treatment decisions | âś“ | âś“ | âś“ | 89% | 84% | 98% | 99% | 90% | |||||||
CPGs help decision making during treatment complications, to double check treatment decisions, especially when clinicians don’t do not have access to MDTs and are clinically useful | ✓ | 59% | 89% | ||||||||||||
CPGs reduced practice variation and increased the uniformity of care across disciplines | âś“ | ||||||||||||||
CPGs help clinicians and patients to reach agreement | 86% | ||||||||||||||
CPGs increased the confidence of clinicians | 64% | ||||||||||||||
Support clinicians’ legal defense when they are adhered to | 41% | 54% | 42% | ||||||||||||
CPG recommendations are balanced in terms of harms and benefits | 59% | ||||||||||||||
A “multidisciplinary focus” is important in CPGs | 94% | ||||||||||||||
Not being prescriptive is considered a strength of CPGs | 59% | ||||||||||||||
CPGs are part of routine practice | 97% | ||||||||||||||
CPGs improve patient wellbeing | 80% | ||||||||||||||
CPGs improve patient survival, outcomes and quality of care | 52% | 47% | 46% | ||||||||||||
CPGs are intended to enhance the quality of patient care | 89% | 95% | 98% | ||||||||||||
CPGs are intended to minimize healthcare costs | 51% |