Knowledge, attitudes and beliefs towards management of men with locally advanced prostate cancer following radical prostatectomy: an Australian survey of urologists

Clinician attitudes towards cancer treatment guidelines in Australia

OBJECTIVES

Clinical Practice Guidelines (CPGs) are designed to guide treatment decisions, yet adherence rates vary widely. To characterise perceived barriers and facilitators to cancer treatment CPG adherence in Australia, and estimate the frequency of previous qualitative research findings, a survey was distributed to Australian oncologists.

RESULTS

The sample is described and validated guideline attitude scores reported for different groups. Differences in mean CPG attitude scores across clinician subgroups and associations between frequency of CPG use and clinician characteristics were calculated; with 48 respondents there was limited statistical power to find differences. Younger oncologists (< 50 years) and clinicians participating in three or more Multidisciplinary Team Meetings were more likely to routinely or occasionally use CPGs. Perceived barriers and facilitators were identified. Thematic analysis was conducted on open-text responses. Results were integrated with previous interview findings and presented in a thematic, conceptual matrix. Most barriers and facilitators identified earlier were corroborated by survey results, with minor discordance. Identified barriers and facilitators require further exploration within a larger sample to assess their perceived impact on cancer treatment CPG adherence in Australia, as well as to inform future CPG implementation strategies. This research was Human Research Ethics Committee approved (2019/ETH11722 and 52019568810127, ID:5688).

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Clinicians' attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature

Background

Clinical Practice Guidelines (CPGs) synthesize the best available evidence to guide clinician and patient decision making. There are a multitude of barriers and facilitators to clinicians adhering to CPGs; however, little is known about active cancer treatment CPG adherence specifically. This systematic review sought to identify clinician attitudes, and perceived barriers and facilitators to active cancer treatment CPG adherence.

Methods

A systematic search was undertaken of five databases; Ovid Medline, PsychInfo, Embase, Scopus, CINAHL, and PROQUEST. The retrieved abstracts were screened for eligibility against inclusion criteria, and a full text review was conducted of all eligible studies. Data were extracted, and a quality assessment was conducted of all included studies. The qualitative papers were thematically analyzed. Attitudes, barriers, and facilitating factors extracted from the quantitative papers were categorized within the qualitative thematic framework.

Results

The search resulted in the identification of 9676 titles. After duplicates were removed, abstracts screened, and full texts reviewed, 15 studies were included. Four themes were identified which related to negative clinician attitudes and barriers to active cancer treatment CPG adherence: (1) concern over CPG content and currency of CPGs; (2) concern about the evidence underpinning CPGs; (3) clinician uncertainty and negative perceptions of CPGs; and (4) organizational and patient factors. The review also identified four themes related to positive attitudes and facilitators to active cancer treatment CPG adherence: (5) CPG accessibility and ease of use; (6) endorsement and dissemination of CPGs and adequate access to treatment facilities and resources; (7) awareness of CPGs and belief in their relevance; and (8) belief that CPGs support decision making, improve patient care, reduce clinical variation, and reduce costs.

Conclusion

These results highlight that adherence to active cancer treatment CPG recommendations by oncology clinicians is influenced by multiple factors such as attitudes, practices, and access to resources. The review has also revealed many similarities and differences in the factors associated with general CPG, and active cancer treatment CPG, adherence. These findings will inform tailored implementation strategies to increase adherence to cancer treatment CPGs.

Trial registration

PROSPERO (2019) CRD42019125748.

Clinicians' attitudes to oncology clinical practice guidelines and the barriers and facilitators to adherence: a mixed methods study protocol

INTRODUCTION

Clinical practice guidelines (CPGs) are designed to reduce inappropriate clinical variation and improve the quality of care. Barriers to CPGs include a lack of awareness of CPGs, access to them, time pressures and concerns regarding the evidence underpinning CPG development, implementation and dissemination. The objectives of this study are to assess clinicians' attitudes to CPGs for cancer treatment and the perceived barriers to and facilitators of CPG adherence in order to inform the implementation of cancer treatment CPGs.

METHODS AND ANALYSIS

A mixed methods study will be conducted using a three-phase, sequential design, with each phase informing the next. In phase 1, a qualitative study using recorded interviews will investigate clinicians' attitudes to CPGs for cancer treatment and perceptions of barriers and facilitators to CPG adherence (n=30); interview transcripts will be analysed thematically. In phase 2, a survey will quantify the frequency of attitudes, barriers and facilitators identified in phase 1, in a broader clinical sample (n=200). In phase 3, a workshop forum will be held to facilitate discussions examining the implications of phase 1 and 2 findings for cancer CPG implementation strategies (n=40) leading to recommendations for improvements to practice. The workshop discussion will be recorded, and the transcript will be analysed thematically.

ETHICS AND DISSEMINATION

This study has received ethics approval in New South Wales, Australia (2019/ETH11722, #52019568810127). Study findings will be published in peer-reviewed journals and will form part of a doctoral thesis and be presented at national and international conferences.

Urologists' referral and radiation oncologists' treatment patterns regarding high-risk prostate cancer patients receiving radiotherapy within 6 months after radical prostatectomy: A prospective cohort analysis

INTRODUCTION

Previous studies have observed low rates of adjuvant radiotherapy after radical prostatectomy (RP) for high-risk prostate cancer patients. However, it is not clear the extent to which these low rates are driven by urologists' referral and radiation oncologists' treatment patterns.

METHOD

The Clinician-Led Improvement in Cancer Care (CLICC) implementation trial was conducted in nine public hospitals in New South Wales, Australia. Men who underwent RP for prostate cancer during 2013-2015 and had at least one high-risk pathological feature of extracapsular extension, seminal vesicle invasion and/or positive surgical margins were included in these analyses. Outcomes were as follows: (i) referral to a radiation oncologist within 4 months after RP ('referred'); (ii) commencement of radiotherapy within 6 months after RP among those who consulted a radiation oncologist ('radiotherapy after consultation').

RESULTS

Three hundred and twenty-five (30%) of 1071 patients were 'referred', and 74 (61%) of 121 patients received 'radiotherapy after consultation'. Overall, the probability of receiving radiotherapy within 6 months after RP was 15%. The probability of being 'referred' increased according to higher 5-year risk of cancer-recurrence (P < 0.001).

CONCLUSION

Only 30% of patients with high-risk features are referred to a radiation oncologist with the likelihood of referral being influenced by the perceived risk of cancer-recurrence as well as the urologist's institutional/personal preference. When patients are seen by a radiation oncologist, 61% receive radiotherapy within 6 months after RP with the likelihood of receiving radiotherapy not being heavily influenced by increasing risk of recurrence. This suggests many suitable patients would receive radiotherapy if referred and seen by a radiation oncologist.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial

BACKGROUND

This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations.

METHODS

Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability.

RESULTS

Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%).

CONCLUSIONS

The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.

An objective measurement of urinary continence recovery with pelvic floor physiotherapy following robotic assisted radical prostatectomy

Background

To assess the impact of structured pelvic floor physiotherapy including repeated standardized measurements in regaining urinary continence in those men who have undergone a robotic-assisted laparoscopic radical prostatectomy (RALP).

Methods

A retrospective database was created on men who had undergone a RALP while under the care of two senior urological surgeons between January 2013 and July 2016 and then took part in a formal pelvic floor rehabilitation program were included in the study. Men were initially seen pre-operatively and then after removal of their indwelling catheter commenced their structured continence program. They were instructed to record their pad weights commencing at week four post-RALP. For each subsequent week, an average of the 24-hour urine leakage was recorded and compared to their first recorded week (baseline) to assess improvement of urinary continence over time.

Results

Forty-five men with a median age of 63.7 years were followed up for a mean of 11.3 weeks post-operatively. The mean daily urine leakage during the first recorded week was 408.0 mL. This decreased to 205.8 and 110.1 mL at 2 and 3 months post-RALP (P<0.05). This equated to a significant 57.1% (95% CI, 52.9% to 61.3%) and 75.6% (95% CI, 72.3% to 78.8%) improvement in urinary leakage at the same respective time points.

Conclusions

There is considerable improvement of urinary leakage following RALP in the short-term in men who participated in a structured, physiotherapist-led pelvic floor re-training program.