Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

Abstract

Background The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers. Methods The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127). Results Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body. Conclusion Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review

“…GRT was associated with increased survival rates for patients with breast cancer, 66 DLBCL, 69 lung cancer, 54,118 cervical cancer, 59 and colon cancer. 62 Of the 20 studies included in this review, 15 39 This supports the need for further generation of real-world data 76 to build the evidence base to guide cancer treatments for older patients, those with later stage disease and comorbidities, in addition to the healthier and younger patients typically included in clinical trials. 38 Low SES was associated with poor GRT in lung cancer 57,118 ; however, the opposite was true for stages B and C rectal cancer patients, potentially as a result of patient preference, or clinical factors that influence treatment decisions.…”

“…Recent research has identified perceived barriers (such as outdated recommendations) and facilitators (such as multidisciplinary peer review) to cancer treatment CPG adherence in Australia, 39 and internationally, 38 and demonstrated that clinician adherence to CPGs is influenced by a multitude of factors, including the quality of CPG development, frequency of updates, patient, clinician and organizational factors, as well as dissemination, and implementation strategies 38,39,74 . These findings add texture by highlighting CPG adherence factors specific to various cancer streams, and in combination, these local contextual factors will inform cancer treatment CPG implementation strategies to address the barriers specific to CPG adherence in Australia, as guided by the Knowledge to Action framework 75 or other implementation frameworks.…”

“…These include content and format, agreement with the underlying evidence, the applicability of GRT to individual patients, CPG currency, and prescriptiveness of the recommendations. 38,39 Similarly, organizational and clinician factors, such as disciplinary preferences and biases, access to treatment options, clinical culture of peer review and multidisciplinary care coordination, and patient specific factors influence adherence. 38,39 Patient and health specific factors, such as older patient age and comorbidities, also influence adherence to CPGs across a variety of cancers, 40,41 including cancers of the breast, 3,12 lung, 42 colon, 10 and head and neck.…”

“…A plethora of variables influences adherence to cancer treatment CPGs, including factors related to CPG development. These include content and format, agreement with the underlying evidence, the applicability of GRT to individual patients, CPG currency, and prescriptiveness of the recommendations 38,39 . Similarly, organizational and clinician factors, such as disciplinary preferences and biases, access to treatment options, clinical culture of peer review and multidisciplinary care coordination, and patient specific factors influence adherence 38,39 …”

Symptom management care pathway adaptation process and specific adaptation decisions

“…There may be challenges to care pathway implementation [ 24 – 29 ]. We included an interprofessional review stage in our procedures to facilitate implementation.…”