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Theme 1 Barriers: concern over CPG content and currency of CPGs
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CPGs are “Biased” [7] (p. 1459)
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Some CPG recommendations are biased
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CPGs lack “applicability to the practice population” [7] (p. 1460)
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CPG are not always applicable to specific settings or feasible
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CPGs are not always clear
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CPGs are “not easy to use” [7] (p. 1461)
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CPGs can be hard to read
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Outdated CPGs, or slow to be updated
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CPGs are “Oversimplified and cookbook medicine” [7] (p. 1461), 13
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Some CPGs are perceived to lead to cookbook medicine that oversimplifies treatment decisions
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CPGs are “Cumbersome and confusing” [7] (p. 1461)
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Some CPGs are too complicated or complex to follow
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CPGs are “Impractical and too rigid to apply” [7] (p. 1459), 13
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Some CPGs are too rigid to apply to practice
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CPGs do not always take into account patient preferences or circumstances
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CPGs lack “credibility by guideline authors” [7] (p. 1460)
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Some CPGs were developed by people not engaged with clinical practice
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Concerned that CPGs are intended to cut costs
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Theme 2 Barriers: concern about the evidence underpinning CPGs
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CPGs underpinned by controversial evidence or a lack of evidence
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Clinical trial patient populations not reflective of the patients seen routinely by clinicians
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Contradicting CPGs that provide contradicting or controversial recommendations or advice
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Clinicians “disagreed with a guideline due to differences in interpretation of the evidence” [7] (p. 1460)
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Preference for own interpretation of the evidence over the synthesis of evidence in CPGs
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CPGs do not always take into account clinical experience
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Theme 3 Barriers: clinician uncertainty and negative perceptions towards CPGs
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Clinicians reported concern about: A “lack of motivation” to change routines and “Inertia of Previous Practice” [7] (p. 1459)
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Clinical equipoise and practice habits that differ to the CPG recommendations
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A lack of “outcome expectancy” [7] (p. 1461)
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A lack of outcome expectation of the CPG recommendations
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That CPG “benefits were not worth patient risk, discomfort or cost” [7] (p. 1460)
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Concerns about side effects associated with CPG recommendations
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Experience of patient adverse effects from CPG treatments
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“A lack of self-efficacy” [7] (p. 1459)
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Limited medical expertise to implement the CPG recommendation
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A perception that the CPG treatments are not necessarily appropriate for specific patients
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A “lack of familiarity” and “awareness” of CPG [7] (p. 1459) 13
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A lack of awareness of CPGs
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“Reduced autonomy” [7] (p. 1460) [13], would decrease flexibility [7]
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CPGs challenged clinician authority or autonomy
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Some CPGs limit the application of clinical judgment
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A “lack of agreement” with the CPG [7] (p. 1460)
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Clinicians disagreeing with specific CPG recommendations
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Limited experience with CPG recommended treatments
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CPGs “will increased litigation or disciplinary action” [13] (p. 504)
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Concerned that CPGs will expose them to litigation issues
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Theme 4 Barriers: organizational and patient factors
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Limited access to treatment services
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Treatment referral processes that are slow
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Referral processes that are unreliable
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Referral processes that are complex
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Surgeons’ hesitancy to refer patients to other clinicians
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A lack of support from organizational and clinical leadership
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CPG recommendations are not always cost effective
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Clinicians reported barriers to adherence including “Patient factors” or characteristics [7] (p. 1459) [11], which may include factors like Patient preferences regarding treatment, Patient comorbidities and tumor specific characteristics [11]
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Patient preferences regarding treatment choice
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Patient comorbidities and tumor specific characteristics
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The level of family support available to patients, and access to transport influences the treatment provided
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Family perceptions of or experiences of treatments were found to influence patient attitudes
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The age of the patient
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Concerns that costs of treatments or concern that adhering to CPG will increase healthcare costs, and other external barriers
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Poor accessibility to CPGs
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Theme 5 Facilitators: CPG accessibility and ease of use
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Having highly skilled clinicians with adequate expertise to implement the CPG is important
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CPGs should be thought of as guides
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CPGs that are evidence based are more likely to be adhered to [11]
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Some CPGs are considered good summaries of up-to-date evidence
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Easy to use CPGs were more likely to be followed, if they don’t require specialized resources and can be easily trialed [11]
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Some CPGs are considered easy to understand
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Some CPGs are considered flexible
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Some CPGs are considered implementable
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User-friendly formats were considered a strength of CPGs
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Some CPGs are developed in a timely manner
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CPGs should be updated regularly
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Adapting and revising CPGs to cater for local needs, and holding meetings about the revised CPG is an important factor
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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
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Theme 6 Facilitators: endorsement and dissemination of CPGs along with adequate resources
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Clinician and clinical organizational support are important
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Collaboration between clinical disciplines in Multi-Disciplinary Teams (MDTs) is important
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Easy access to treatment services for patients is important
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CPG dissemination via medical college programs is important
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CPG endorsement by government research organizations is important
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CPG endorsement by medical colleges is important
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Recommendations by respected peers, or discussions with respected peers is important
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Symposia about CPGs are important
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Provision of emails or websites that summarized updated CPGs, or current clinical trials underpinning CPGs are important
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Access to treatment facilities and adequate resources to implement CPGs is important
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Audits and feedback are important
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Multidisciplinary clinical care pathways or MDT discussions increase awareness of CPGs
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Theme 7 Facilitators: awareness of CPGs and belief in their relevance
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High clinician awareness of CPGs
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Agreement with and support for CPG recommendations
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Confidence in CPGs was high when the guidelines were considered high quality
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Use of or compliance with CPGs was generally reported to be high
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CPGs should be “developed by credible individuals” and include lists of CPG committee members should be published
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Financial disincentives for surgeons who do not follow the guidelines
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Theme 8 Facilitators: CPGs support decision making, improve patient care, reduce clinical variation and reduce costs
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CPGs were considered to be “helpful sources of advice” and information [13] (p. 504)
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CPS are good, convenient sources of advice or information with unambiguous recommendations
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CPGs were considered to be “good educational tools” for making treatment decisions [13] (p. 504)
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CPS are considered to be good, useful and educational tools for making treatment decisions that help clinicians orientate treatment decisions
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CPGs help decision making during treatment complications, to double check treatment decisions, especially when clinicians don’t do not have access to MDTs
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CPGs reduced practice variation and increased the uniformity of care across disciplines
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CPGs help clinicians and patients to reach agreement
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CPGs increased the confidence of clinicians
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Support clinicians’ legal defense when they are adhered to
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CPG recommendations are balanced in terms of harms and benefits
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CPGs are clinically useful
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A “multidisciplinary focus” is important in CPGs
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Not being prescriptive is considered a strength of CPGs
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CPGs are part of routine practice
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CPGs improve patient wellbeing
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CPGs improve patient survival, outcomes and quality of care
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CPGs were “intended to improve the quality of care” [13] (p. 504)
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CPGs are intended to enhance the quality of patient care
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CPGs were “intended to cut health care costs” [13] (p. 504)
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CPGs are intended to minimize healthcare costs
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