Asfour, Sara (2019). In primary health care, what are the key barriers to the implementation of guideline recommendations for breast cancer survivors? a mixed methods study. McGill Family Medicine Studies Online, 14: e09

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Abstract

Background The cancer survival rate has increased. As cancer care evolves, new challenges are emerging. A growing number of FPs follow cancer survivors, who often have long-term problems because of their cancer or its treatment. FPs are willing to provide care to cancer survivors but they face obstacles. Survivorship guidelines exist but FPs are not aware of them. While we know about barriers to the implementation of guideline recommendations by clinicians (in general), we know little about survivorship guideline implementation in primary health care.

Objectives The specific objectives of my study are (i) to measure the frequency of non-use of breast cancer survivorship guideline recommendations by family physicians (FPs) using the IAM Medical Guidelines mobile application and (ii) to describe key barriers to the implementation of these recommendations from the FP perspective in settings where they practice.

Methodology and methodsI conducted a convergent mixed methods study. Participants were FPs providing care to at least one breast cancer survivor. Quantitative component: We integrated 21 key guideline recommendations in a mobile application. Through the app, we delivered a weekly alert to one new key guideline recommendation. FPs could rate each recommendation using the validated Information Assessment Method (IAM) questionnaire. I identified patterns of non-use of recommendations. Qualitative component: I conducted interviews with 16 FPs who answered "no" or "possibly" to the question concerning the use of a recommendation for at least one of their patients. I identified barriers to implementation of each key guideline recommendation and assigned them to a series of themes related to non-use of information. Integration: I compared and combined results of the quantitative and qualitative components.

ResultsIn the quantitative component, 22 of 29 (76%) participants who rated recommendations answered "no" or "possibly" to the IAM question about the use of a recommendation. Participants reported disagreeing with the content of the information or found a problem with the presentation of the information for 8 guideline recommendations: follow-up, breast self-exam, alcohol consumption, vaccines, pain, distress screening, hot flushes and osteoporosis/ bone health. Six recommendations were reported as not used: follow-up, screening, non-routine tests, nutrition, distress screening and hot flushes. In the qualitative component, many barriers were identified and grouped into themes. Barriers were related to the FP social and professional role and identity, social influences, knowledge, beliefs about consequences, memory, environmental context and resources, goals, reinforcement, skills, information characteristics and patient related factors.

Discussion and conclusionThis study revealed new barriers, not reported in the literature: lack of memory for the guideline recommendation, lack of opportunity to use the guideline recommendation, lack of guideline awareness by patients and lack of information materials for patients. The identification of barriers to implementation of survivorship guideline recommendations through an innovative and validated method may help to develop interventions to improve clinical care at the individual and organizational levels.