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

Kastner M, Estey E, Hayden L, Chatterjee A, Grudniewicz A, Graham ID, Bhattacharyya O - BMC Fam Pract (2014)

Bottom Line: 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.Our 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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Li Ka Shing Knowledge Institute of St, Michael's Hospital, 209 Victoria Street, Toronto, Ontario, Canada. monika.kastner@utoronto.ca.

ABSTRACT

Background: The 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.

Methods: We conducted a qualitative study with family physicians in Toronto, 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.

Results: 20 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.

Conclusions: Our 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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Three draft recommendations presented to family physicians (Objective 2), depicting their perceptions of problems identified in the original recommendation and their suggestions for revising. A. Draft recommendation 1 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. B. Draft recommendation 2 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. C. Draft recommendation 3 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising
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Figure 3: Three draft recommendations presented to family physicians (Objective 2), depicting their perceptions of problems identified in the original recommendation and their suggestions for revising. A. Draft recommendation 1 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. B. Draft recommendation 2 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. C. Draft recommendation 3 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising

Mentions: There was low agreement with the 3 draft recommendation statements for several reasons. First, physicians thought that the statements were impractical (N = 11) as they did not consider the necessary resources to perform the recommendations or were incongruent with provider and patient values. To address this problem, physicians suggested individualizing recommendations by considering costs, human resources and provider and patient values in their recommendations. Second, physicians thought that the recommendations lacked clinical sense (N = 6) as there was no clear direction of action or information was missing. Suggestions were to use clear and actionable language such as active voice, the provision of more background information, to include clear targets for patient outcomes, and to include information on the benefits and harms of treatments. Another factor affecting participants’ agreement with statements was the apparent poor evidence supporting them. In such cases, physicians suggested omitting detailed and specific guidance in order to simplify recommendations. Lastly, participants perceived the recommendations to be too aggressive to apply (N = 4), that is the specified clinical targets were either not achievable or suggested interventions were more intense than what they thought their patients would prefer (e.g., being on 3 medications instead of 1 or monitoring twice a day instead of once a day). To address these issues, physicians suggested providing more background information, acknowledging that the statement represents a change from current practice, and to underscore the rationale for such changes. Figures 3A-C show each of the three original draft recommendations and the revised statements according to family physicians suggestions.


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

Kastner M, Estey E, Hayden L, Chatterjee A, Grudniewicz A, Graham ID, Bhattacharyya O - BMC Fam Pract (2014)

Three draft recommendations presented to family physicians (Objective 2), depicting their perceptions of problems identified in the original recommendation and their suggestions for revising. A. Draft recommendation 1 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. B. Draft recommendation 2 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. C. Draft recommendation 3 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4016596&req=5

Figure 3: Three draft recommendations presented to family physicians (Objective 2), depicting their perceptions of problems identified in the original recommendation and their suggestions for revising. A. Draft recommendation 1 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. B. Draft recommendation 2 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising. C. Draft recommendation 3 presented to family physicians (Objective 2), depicting their perceptions of problems identified in original recommendation and their suggestions for revising
Mentions: There was low agreement with the 3 draft recommendation statements for several reasons. First, physicians thought that the statements were impractical (N = 11) as they did not consider the necessary resources to perform the recommendations or were incongruent with provider and patient values. To address this problem, physicians suggested individualizing recommendations by considering costs, human resources and provider and patient values in their recommendations. Second, physicians thought that the recommendations lacked clinical sense (N = 6) as there was no clear direction of action or information was missing. Suggestions were to use clear and actionable language such as active voice, the provision of more background information, to include clear targets for patient outcomes, and to include information on the benefits and harms of treatments. Another factor affecting participants’ agreement with statements was the apparent poor evidence supporting them. In such cases, physicians suggested omitting detailed and specific guidance in order to simplify recommendations. Lastly, participants perceived the recommendations to be too aggressive to apply (N = 4), that is the specified clinical targets were either not achievable or suggested interventions were more intense than what they thought their patients would prefer (e.g., being on 3 medications instead of 1 or monitoring twice a day instead of once a day). To address these issues, physicians suggested providing more background information, acknowledging that the statement represents a change from current practice, and to underscore the rationale for such changes. Figures 3A-C show each of the three original draft recommendations and the revised statements according to family physicians suggestions.

Bottom Line: 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.Our 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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Li Ka Shing Knowledge Institute of St, Michael's Hospital, 209 Victoria Street, Toronto, Ontario, Canada. monika.kastner@utoronto.ca.

ABSTRACT

Background: The 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.

Methods: We conducted a qualitative study with family physicians in Toronto, 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.

Results: 20 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.

Conclusions: Our 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.

Show MeSH