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Table 6 Comparison of previously identified factors and factors unique to cancer treatment CPG adherence

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

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  Outdated CPGs, or slow to be updated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