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Table 5 Identified Themes and Subthemes and the proportion of clinicians reporting each subtheme

From: Clinicians’ attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature

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            
Quantitative methods   
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          
Some CPG recommendations are biased                
CPG are not always applicable to specific settings or feasible        25%         
CPGs are not always clear               25%  
CPGs can be hard to read               17%  
Outdated CPGs, or slow to be updated           31%    6%   
Some CPGs are perceived to be cookbook medicine that oversimplifies difficult or controversial treatment decisions       28% 46%   45% 13%    24% 26%  
Some CPGs are too complicated or complex to follow             23%   
Some CPGs are too rigid to apply to practice       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        
CPGs underpinned by controversial evidence or a lack of evidence     30%          
Clinical trial patient populations that does not contain patients that clinicians routinely see    60%            
The existence of contradicting CPGs or CPGs that provide contradicting or controversial recommendations or advice       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        
Clinical equipoise and practice habits that differ to the CPG recommendations           3%      
Concerns about side effects associated with CPG recommendations or past experience of patient adverse effects from CPG recommended treatments    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%        
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        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               
Limited access to treatment services                
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               
The level of family support available to patients, and access to transport influences the treatment provided                
family perceptions of or experiences of treatments were found to influence patient attitudes                
The age of the patient                
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%          
Theme 5 Facilitators: CPG accessibility and ease of use              
Having highly skilled clinicians with adequate expertise to implement the CPG is important                
CPGs should be treated as guides, not rules, to cater to individual patient needs               
Some CPGs are considered good summaries of up-to-date evidence        97%         
Clinicians felt it was important that CPGs were updated regularly               
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               
Clinician and clinical organizational support is important                
Collaboration between clinical disciplines in Multi-Disciplinary Teams (MDTs) is important                
Easy access to treatment services for patients is important                
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  
High clinician awareness of CPGs   49-82% 54%   86% 83% 44-60% 74% 80% 76%
Agreement with and support for CPG recommendations           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     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         
CPS are good, convenient sources of advice or information with unambiguous recommendations       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     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               
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%