Health care personnel’s perception of guideline implementation for musculoskeletal imaging: a process evaluation

Abstract

Background: The increasing complexity and variability in radiology have significantly fueled the need for guidelines. There are many methods for disseminating and implementing guidelines however; and obtaining lasting changes has been difficult. Implementation outcome is usually measured in a decrease in unwarranted examinations, and qualitative data are rarely used. This study's aim was to evaluate a guideline implementation process and identify factors influencing implementation outcome using qualitative data. Methods: Seven general practitioners and five radiological personnel from a Norwegian county participated in four focus group interviews in 2019. The data were analyzed using qualitative content analysis, where some categories were predetermined, while most were drawn from the data. Results: Four main categories were developed from the data material. 1) Successful/unsuccessful parts of the implementation, 2) perceived changes/lack of changes after the implementation, 3) environment-related factors that affected guideline use, and 4) User related factors that affect guideline use. Conclusions: Our findings show that clinical guideline implementation is difficult, despite the implementation strategy being tailored to the target groups. Several environment-and user-related factors contributed to the lack of changes experienced in practice for both general practitioners and radiological personnel.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period

“…This means that the imaging is still performed; however, the imaging may be more justified than it would have been if it was performed at an earlier stage. 32…”

“…However, the feedback missed by the GPs in our study was not referral rated, but rather the quality and justification of their referrals. 32 Reminders have also proven to be effective means to change behavior, 26,36 which potentially could have improved the effect of the implementation. However, it was chosen not to include reminders on the basis of the interviews with GPs and radiologists, as well as discussions with a practice coordinator, where the emphasis was mainly on easy accessibility of guidelines.…”

“…It was offered to a representative of the participating municipality, which may have led to the information not being perceived as equally interesting for all the participants, since some participants viewed the implementation more as a confirmation that their existing practice was correct, rather than as an opportunity to improve. 32 The frequency (or dose) of the implementation may also influence the outcome. In the current study, a repeat of the educational meetings, or other means of repeating the information could imply greater effect on the use of unwarranted imaging, and thereby a significant change in the difference in use of unwarranted imaging between the intervention and control counties.…”

Patient Characteristics and Healthcare Use for High-cost Patients with Musculoskeletal Disorders in Norway: A Cohort Study

“…There are numerous reasons why treatment may or may not adhere to clinical guidelines, such as unfamiliarity with guidelines, disagreement with recommendations, pressure from patients and fear of repercussions (43)(44)(45). Additionally, guidelines are meant only to support decision-making, and not intended as replacement for clinical judgement or to be followed meticulously (46,47).…”

Evaluation of a guidelines implementation intervention to reduce work disability and sick leaves related to chronic musculoskeletal pain: a theory-informed qualitative study in occupational health care

“…Previous research [ 6 – 11 ] has identified physicians’ key pain management behaviours (e.g., diagnosing and treating pain, assessing work disability and the need for sick leave, advising patients with pain) and factors that influence these behaviours (physicians’ knowledge and attitudes, external factors). Interventions aiming to promote physicians’ engagement in behaviours recommended by pain management guidelines may affect physicians’ knowledge and attitudes, but changing actual behaviour is more difficult, especially if organizational, workplace and health care system level factors, such as resources, cultures and policies are not targeted [ 12 – 18 ]. In the OHS intervention, the implementation of the guidelines was supported by three short educational sessions and some coaching sessions for physicians, led by pain specialists.…”