Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey

Abstract

IntroductionThe 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study.MethodsA questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines.Results81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable.ConclusionsThe iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.

Healthcare providers’ adherence to breast cancer guidelines in Europe: a systematic literature review

“…Most studies (n = 36, 87.8%) assessed adherence based on medical records (from hospital databases, specific registers, or national cancer registries), and their sample sizes ranged from 131 [51] to 104,201 records [44]. The remaining five studies (12.2%) were based on self-reported data, through surveys or interviews to healthcare providers [52][53][54][55][56], and their samples sizes ranged from 10 [56] to 202 participants [53]. Adherence to CGs recommendations was the primary outcome in 38 studies (92.6%), while three focused on factors that influence adherence [32,47,56].…”

“…These studies included patients receiving treatment in the period from 1992 to 2008 [20,35,63].The median adherence for surgical procedures was 86.3% (IQR 75.7-89.2%), and ranged from 65 [63] to 92% [35]. Moreover, eleven studies measured adherence for individual surgical procedures which included (1) breast-conserving surgery (BCS) [45,58,[60][61][62], the median adherence was 74% (IQR 75.7-93%), and ranged from 35 [60] to 95% [45]; (2) mastectomy (MA) [25,45,60], the adherence ranged from 54 [60] to 91% [45]; (3) SLNB [58,62,72], from 51 [62] to 76% [72]; (4) ALND [58,59,73], from 68 [58] to 81% [59]; and (5) other indicators included organisational indicators [54] or "breast surgery without needing a second surgery" [57], which reported 17% and 97% of adherent treatment, respectively.…”

“…Five studies [37,38,49,54,74] addressed procedures aimed to prevent adverse events during treatment, including patients receiving treatment in the period between 1996 and 2017. The median adherence was 75% (IQR 63-75%, and ranged from 19 [46] to 96% [37].…”

Perceived barriers to randomised controlled trials in breast reconstruction: obstacle to trial initiation or opportunity to resolve? A qualitative study

“…This work comprises phase 3, the Randomisation Acceptability Phase of the iBRA study (ISRCTN37664281) a multicentre prospective cohort study to inform the feasibility, design and conduct of a large-scale pragmatic RCT in IBBR. The study protocol [25] and results of phases 1 [26,27] and 2 [9] have been published elsewhere. Full ethical approval for phase 3 was obtained from the University of Bristol Faculty of Health Sciences Research Ethics Committee (FREC) Reference 61,501.…”

“…Phase 1 was a national practice questionnaire aiming to survey current practice, with phase 2 involving a multicentre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomes of these procedures. Phase 3 of the study used mixed-methods to investigate the acceptability of candidate trial designs generated in phase 1 [26,27] and phase 2 [9]. This included an electronic survey and qualitative interviews, which aimed to explore the acceptability of proposed RCT designs and possible barriers to RCT conduct in IBBR, from the perspective of those who would be potential trial recruiters.…”