Facilitators and barriers to clinical practice guideline-consistent supportive care at pediatric oncology institutions: a Children's Oncology Group study

Aaron J Sugalski, Tammy Lo, Melissa Beauchemin, Allison C Grimes, Paula D Robinson, Alexandra M Walsh, Nancy Santesso, Ha Dang, Brian T Fisher, Andrea Rothfus Wrightson, Lolie C Yu, Lillian Sung, L Lee Dupuis, Aaron J Sugalski, Tammy Lo, Melissa Beauchemin, Allison C Grimes, Paula D Robinson, Alexandra M Walsh, Nancy Santesso, Ha Dang, Brian T Fisher, Andrea Rothfus Wrightson, Lolie C Yu, Lillian Sung, L Lee Dupuis

Abstract

Background: Clinical practice guideline (CPG)-consistent care improves patient outcomes, but CPG implementation is poor. Little is known about CPG implementation in pediatric oncology. This study aimed to understand supportive care CPG implementation facilitators and barriers at pediatric oncology National Cancer Institute (NCI) Community Oncology Research Program (NCORP) institutions.

Methods: Healthcare professionals at 26 pediatric, Children's Oncology Group-member, NCORP institutions were invited to participate in face-to-face focus groups. Serial focus groups were held until saturation of ideas was reached. Supportive care CPG implementation facilitators and barriers were solicited using nominal group technique (NGT), and implementation of specific supportive care CPG recommendations was discussed. Notes from each focus group were analyzed using a directed content analysis. The top five themes arising from an analysis of NGT items were identified, first from each focus group and then across all focus groups.

Results: Saturation of ideas was reached after seven focus groups involving 35 participants from 18 institutions. The top five facilitators of CPG implementation identified across all focus groups were organizational factors including charging teams with CPG implementation, individual factors including willingness to standardize care, user needs and values including mentorship, system factors including implementation structure, and implementation strategies including a basis in science. The top five barriers of CPG implementation identified were organizational factors including tolerance for inconsistencies, individual factors including lack of trust, system factors including administrative hurdles, user needs and values including lack of inclusivity, and professional including knowledge gaps.

Conclusions: Healthcare professionals at pediatric NCORP institutions believe that organizational factors are the most important determinants of supportive care CPG implementation. They believe that CPG-consistent supportive care is most likely to be delivered in organizations that prioritize evidence-based care, provide structure and resources to implement CPGs, and eliminate implementation barriers.

Trial registration: ClinicalTrials.gov Identifier: NCT02847130. Date of registration: July 28, 2016.

Keywords: Clinical practice guideline; Oncology; Pediatrics; Supportive care.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

References

    1. Clinical practice guidelines . directions for a new program, Institute of Medicine. Washington, DC: National Academy Press; 1990.
    1. Wright JD, Neugut AI, Ananth CV, Lewin SN, Wilde ET, Lu YS, Herzog TJ, Hershman DL. Deviations from guideline-based therapy for febrile neutropenia in cancer patients and their effect on outcomes. JAMA Internal Med. 2013;173(7):559–568. doi: 10.1001/jamainternmed.2013.2921.
    1. Aapro M, Molassiotis A, Dicato M, Pelaez A, Rodriguez-Lescure A, Pastorelli D, et al. The effect of guideline-consistent antiemetic therapy on chemotherapy-induced nausea and vomiting (CINV): the Pan European Emesis Registry (PEER) Ann Oncol. 2012;23(8):1986–1992. doi: 10.1093/annonc/mds021.
    1. Wockel A, Kurzeder C, Geyer V, Novasphenny I, Wolters R, Wischnewsky M, et al. Effects of guideline adherence in primary breast cancer - a 5-year multi-center cohort study of 3976 patients. Breast. 2010;19(2):120–127. doi: 10.1016/j.breast.2009.12.006.
    1. Nieuwlaat R, Olsson S, Lip G, Camm A, Breithardt G, Capucci A, Meeder JG, Prins MH, Lévy S, Crijns HJ, Euro Heart Survey Investigators Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrilllation. The Euro heart survey on atrial fibrillation. Am Heart J. 2007;153(6):1006–1012. doi: 10.1016/j.ahj.2007.03.008.
    1. Olver I, Keefe D, Herrstedt J, Warr D, Roila F, Ripamonti CI. Supportive care in cancer—a MASCC perspective. Support Care Cancer. 2020;28(8):3467–3475. doi: 10.1007/s00520-020-05447-4.
    1. Children’s Oncoloogy Group. Children’s Oncology Group Supportive Care Endorsed Guidelines: Children’s Oncology Group; [Available from: .
    1. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6:26. doi: 10.1186/1748-5908-6-26.
    1. FitzGerald JM, Boulet LP, McIvor RA, Zimmerman S, Chapman KR. Asthma control in Canada remains suboptimal: the Reality of Asthma Control (TRAC) study. Can Respir J. 2006;13(5):253–259. doi: 10.1155/2006/753083.
    1. Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. J Gen Intern Med. 2006;21(Suppl 2):S14–S20.
    1. Latosinsky S, Fradette K, Lix L, Hildebrand K, Turner D. Canadian breast cancer guidelines: have they made a difference? CMAJ. 2007;176(6):771–776. doi: 10.1503/cmaj.060854.
    1. Correa VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, Contreras JAP, Borrero AMP, Patiño-Lugo DF, et al. Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health Res Policy Syst. 2020;18(1):1–11. doi: 10.1186/s12961-020-00588-8.
    1. Unguru Y. The successful integration of research and care: how pediatric oncology became the subspecialty in which research defines the standard of care. Pediatr Blood Cancer. 2011;56(7):1019–1025. doi: 10.1002/pbc.22976.
    1. Flottorp S, Oxman A, Krause J, Musila N, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8(1):35. doi: 10.1186/1748-5908-8-35.
    1. Tavender EJ, Bosch M, Fiander M, Knott JC, Gruen RL, O’Connor D. Implementation research in emergency medicine: a systematic scoping review. Emerg Med J. 2016;33(9):652–659. doi: 10.1136/emermed-2015-205053.
    1. U.S. Department of Health and Human Services. National Cancer Institute Community Oncology Research Program (NCORP) [Available from: .
    1. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–1251. doi: 10.1097/ACM.0000000000000388.
    1. McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655–662. doi: 10.1007/s11096-016-0257-x.
    1. Willis GB. Cognitive interviewing: a tool for improving questionnaire design. Thousand Oaks, Calif: Sage Publications; 2005.
    1. Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: SAGE; 2009.
    1. Krueger RA. Moderating focus groups. Thousand Oaks: Sage Publications, Inc; 1998.
    1. Krueger RA. Developing questions for focus groups. Thousand Oaks SAGE Publications, Inc.; 1998, DOI: 10.4135/9781483328126.
    1. Hoekstra F, McBride CB, Borisoff J, Fetterly M-J, Ginis S, Latimer-Cheung AE, et al. Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource. Spinal Cord. 2020;58(6):647–657. doi: 10.1038/s41393-019-0410-1.
    1. Jin Y, Li Z, Han F, Huang D, Huang Q, Cao Y, Weng H, Zeng XT, Wang X, Shang HC. Barriers and enablers for the implementation of clinical practice guidelines in China: a mixed-method study. BMJ Open. 2019;9(9):e026328. doi: 10.1136/bmjopen-2018-026328.
    1. EisBrenner T, Tipples G, Kuschak T, Gilmour M. Laboratory biosafety: laboratory response checklist for infectious disease outbreaks—preparedness and response considerations for emerging threats. Can Commun Dis Rep. 2020;46(10):311–321. doi: 10.14745/ccdr.v46i10a01.
    1. McMillan SS, Kelly F, Sav A, Kendall E, King MA, Whitty JA, et al. Using the nominal group technique: how to analyse across multiple groups. Health Serv Outcome Res Methodol. 2014;14(3):92–108. doi: 10.1007/s10742-014-0121-1.
    1. National Cancer Institute . Implementation science at a glance: a guide for cancer control practitioners. U.S: Department of Health and Human Services; 2019. p. 21.
    1. Bierbaum M, Rapport F, Arnolda G, Nic Giolla Easpaig B, Lamprell K, Hutchinson K, et al. Clinicians’ attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature. Implement Sci. 2020;15:1–24. doi: 10.1186/s13012-020-00991-3.
    1. De Clercq E, Rost M, Pacurari N, Elger BS, Wangmo T. Aligning guidelines and medical practice: literature review on pediatric palliative care guidelines. Palliat Support Care. 2017;15(4):474–489. doi: 10.1017/S1478951516000882.
    1. Restall G, Diaz F, Wittmeier K. Why do clinical practice guidelines get stuck during implementation and what can be done: a case study in pediatric rehabilitation. Phys Occup Therapy Pediatr. 2020;40(2):217–230. doi: 10.1080/01942638.2019.1660447.
    1. Jun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses’ use of clinical practice guidelines: an integrative review. Int J Nurs Stud. 2016;60:54–68. doi: 10.1016/j.ijnurstu.2016.03.006.
    1. Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P. Facilitating clinician adherence to guidelines in the intensive care unit: a multicenter, qualitative study. Crit Care Med. 2007;35(9):2083–2089. doi: 10.1097/01.ccm.0000281446.15342.74.
    1. Loeffen E, Kremer L, Mulder R, Font-Gonzalez A, Dupuis L, Sung L, et al. The importance of evidence-based supportive care practice guidelines in childhood cancer—a plea for their development and implementation. Support Care Cancer. 2017;25(4):1121–1125. doi: 10.1007/s00520-016-3501-y.
    1. Baggott C, Dodd M, Kennedy C, Marina N, Matthay KK, Cooper BA, Miaskowski C. Changes in children's reports of symptom occurrence and severity during a course of myelosuppressive chemotherapy. J Pediatr Oncol Nurs. 2010;27(6):307–315. doi: 10.1177/1043454210377619.
    1. Miller E, Jacob E, Hockenberry MJ. Nausea, pain, fatigue, and multiple symptoms in hospitalized children with cancer. Oncol Nurs Forum. 2011;38(5):E382–E393. doi: 10.1188/11.ONF.E382-E393.
    1. Poder U, Ljungman G, von Essen L. Parents’ perceptions of their children's cancer-related symptoms during treatment: a prospective, longitudinal study. J Pain Symptom Manag. 2010;40(5):661–670. doi: 10.1016/j.jpainsymman.2010.02.012.
    1. Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966–969. doi: 10.1002/pbc.24946.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera