The development of a guideline implementability tool (GUIDE-IT): a qualitative study of family physician perspectives

Abstract

BackgroundThe potential of clinical practice guidelines has not been realized due to inconsistent adoption in clinical practice. Optimising intrinsic characteristics of guidelines (e.g., its wording and format) that are associated with uptake (as perceived by their end users) may have potential. Using findings from a realist review on guideline uptake and consultation with experts in guideline development, we designed a conceptual version of a future tool called Guideline Implementability Tool (GUIDE-IT). The tool will aim to involve family physicians in the guideline development process by providing a process to assess draft guideline recommendations. This feedback will then be given back to developers to consider when finalizing the recommendations. As guideline characteristics are best assessed by end-users, the objectives of the current study were to explore how family physicians perceive guideline implementability, and to determine what components should comprise the final GUIDE-IT prototype.MethodsWe conducted a qualitative study with family physicians inToronto, Ontario. Two experienced investigators conducted one-hour interviews with family physicians using a semi-structured interview guide to 1) elicit feedback on perceptions on guideline implementability; 2) to generate a discussion in response to three draft recommendations; and 3) to provide feedback on the conceptual GUIDE-IT. Sessions were audio taped and transcribed verbatim. Data collection and analysis were guided by content analyses.Results20 family physicians participated. They perceived guideline uptake according to facilitators and barriers across 6 categories of guideline implementability (format, content, language, usability, development, and the practice environment). Participants’ feedback on 3 draft guideline recommendations were grouped according to guideline perception, cognition, and agreement. When asked to comment on GUIDE-IT, most respondents believed that the tool would be useful, but urged to involve “regular” or community family physicians in the process, and suggested that an online system would be the most efficient way to deliver it.ConclusionsOur study identified facilitators and barriers of guideline implementability from the perspective of community and academic family physicians that will be used to build our GUIDE-IT prototype. Our findings build on current knowledge by showing that family physicians perceive guideline uptake mostly according to factors that are in the control of guideline developers.

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“…The interviewer asked participants to reflect on any factors that would facilitate or prohibit them from using the tool. Items derived from the GUIDE-IT tool framed questions of the initial interview guide that addressed the tool's implementability [35]. Participants were also asked about how they think the tool should be introduced to clinicians and how to have it available at their practice sites.…”

Naturalistic study of guideline implementation tool use via evaluation of website access and physician survey

“…In focus groups and interviews with 62 medical directors about how to increase use of the American College of Occupational and Environmental Medicine’s guidelines, the need for quick reference tools was a high priority [30]. In interviews and focus groups with 20 family physicians about their preferences for guideline content and format, participants expressed the need for guideline summaries including charts, tables and algorithms [31]. Interviews with 28 health professionals from four intensive care units revealed that GItools such as checklists which could be quickly consulted as a reminder were viewed as enablers of guideline implementation [32].…”

Optimizing the language and format of guidelines to improve guideline uptake

“…10 In particular, primary care physicians perceive barriers and facilitators to guideline uptake almost exclusively according to their format, language and usability. 11 Accordingly, the style in which a guideline is written (e.g., providing suggested actions rather than prohibitive rules) influences how it is received and whether it will be followed. 12 In an observational study involving general practitioners in the Netherlands, vague and imprecisely defined recommendations were followed in 36% of clinical decisions, whereas clear recommendations were followed in 67% of decisions.…”

“…Ideally, end-users of a guideline should also be involved in this process. Recent work suggests that primary care physicians can be successfully engaged in objectively assessing language and format attributes of recommendations and improving these according to their preferences 11 (a worksheet from this process is included in Appendix 5, available at www.cmaj.ca/lookup/ suppl/doi: 10.1503/cmaj.151102/-/DC1). Efforts could be initiated by individual guideline committees.…”