Does dissemination of guidelines alone increase the use of palliative single-fraction radiotherapy? Initial report of a longitudinal change management campaign at a provincial cancer program

The implementation of guidelines in palliative care - a scoping review

BACKGROUND

Guidelines are essential tools for ensuring high-quality healthcare. However, discrepancies exist between their availability and practical implementation. In the context of palliative care, the extent to which guidelines are implemented and the barriers and facilitators that influence this process remain unknown.

AIM

The present study aimed at systematically reviewing the international literature on the implementation of palliative care guidelines to evaluate factors that support or hinder implementation of palliative care guidelines globally.

METHOD

A scoping review was conducted following the methodological approach of Arksey and O'Malley (2005). After the formulation of research questions and development of a search string, relevant studies investigating the implementation of guidelines were identified and retrieved from the databases CINAHL, LIVIO, PubMed and Web of Science Core Collection on 4 January 2024. Two researchers independently selected articles for inclusion, employing a blinded process with predefined inclusion and exclusion criteria. The results were subsequently categorised deductively by the same researchers using Petermann's (2014) taxonomy of implementation outcomes. The results were summarised and presented in tabular form.

RESULTS

The search yielded 2,086 records, of which 1,252 were included in the title and abstract screening. Subsequently, 113 full-text articles were reviewed for eligibility, resulting in 29 articles deemed suitable for the final analysis. Six implementation outcomes were identified in the included literature: (1) acceptability (n = 15 articles), (2) adoption (n = 6 articles), (3) appropriateness (n = 9 articles), (4) feasibility (n = 9 articles), (5) fidelity/adherence (n = 14 articles) and (6) penetration (n = 14 articles). The majority of studies employed quantitative approaches (n = 22) and considered the perspective of healthcare professionals and their opinions regarding guideline implementation in palliative care. Only 4 articles considered patient related outcomes or the perspectives of the family caregivers. Ten articles reported on facilitators and barriers. Facilitators included healthcare professionals' motivation and managerial support, while barriers primarily referred to time constraints and limited knowledge.

CONCLUSIONS

Guideline implementation in palliative care is highly variable. Future research should aim at comprehensively analysing facilitators of and barriers to this process, considering diverse implementation outcomes. For these evaluations, mixed-method approaches are recommended.

The Effectiveness of Public Awareness Initiatives Aimed at Encouraging the Use of Evidence-Based Recommendations by Health Professionals: A Systematic Review

OBJECTIVES

Public awareness initiatives have attracted growing attention globally, as a strategy to reduce low-value care and disinformation. However, knowledge gap remains in determining their effects. The aim of this systematic review was to summarize existing evidence to date on global effectiveness of public awareness initiatives.

METHODS

Primary quantitative studies focusing on passive delivery of public awareness initiatives that targeted health professionals were included. Eligible studies were identified through search of MEDLINE, Embase, Emcare, the Cochrane Library, PsycINFO, Business Source Complete, Emerald Insight, and Google (initially on December 19, 2018, followed by updated search between July 8-10, 2019, and then between March 8-9, 2022) and the reference list of relevant studies. Methodological quality of included studies was assessed using modified McMaster critical appraisal tool. A narrative synthesis of the study outcomes was conducted.

RESULTS

Twenty studies from United States, United Kingdom, Canada, Australia, and multicountry were included. Nineteen studies focused on Choosing Wisely initiative and one focused on National Institute of Clinical Excellence reminders. Most studies investigated one recommendation of a specialty. The findings showed conflicting evidence on the effectiveness of public awareness initiatives, suggesting passive delivery has limited success in reducing low-value care among health professionals.

CONCLUSIONS

This review highlights the complexity of change in an established practice pattern in health care. As passive delivery of public awareness initiatives has limited potential to initiate and sustain change, wide-ranging intervention components need to be integrated for a successful implementation.

Prognostic Factors Influencing Survival and a Treatment Pattern Analysis of Conventional Palliative Radiotherapy for Patients with Bone Metastases

BACKGROUND

Treatment indication for bone metastases is influenced by patient prognosis. Single-fraction radiotherapy (SFRT) was proven equally effective as multiple fractionation regimens (MFRT) but continues to be underused.

OBJECTIVE

Primary objectives: (a) to identify prognostic factors for overall survival and (b) to analyze treatment patterns of palliative radiotherapy (proportion of SFRT indication and predictive factors of radiotherapy regimen) for bone metastases.

METHODS

582 patients with bone metastases who underwent conventional radiotherapy between January 1st 2014-31 December 2017 were analyzed. The Cox proportional hazard model was used to identify predictors of overall survival. For the treatment pattern analysis, 677 radiotherapy courses were evaluated. The logistic regression model was used to identify potential predictors of radiotherapy regimen.

RESULTS

The 3-year overall survival was 15%. Prognostic factors associated with poor overall survival were multiple bone metastases [hazard ratio (HR = 5.4)], poor performance status (HR = 1.5) and brain metastases (HR = 1.37). SFRT prescription increased from 41% in 2017 to 51% in 2017. Predictors of SFRT prescription were a poor performance status [odds ratio (OR = 0.55)], lung (OR = 0.49) and urologic primaries (OR = 0.33) and the half-body lower site of irradiation (OR = 0.59). Spinal metastases were more likely to receive MFRT (OR = 2.09).

CONCLUSIONS

Based on the prognostic factors we identified, a selection protocol for patients candidates for palliative radiotherapy to bone metastases could be established, in order to further increase SFRT prescription in our institution.

An Intensive Educational Intervention Significantly Improves the Adoption of Single Fractionation Radiotherapy in Uncomplicated Bone Metastases

Introduction:

An education strategy was employed in our department to increase the rate of patients with uncomplicated painful bone metastases undergoing single fractionation radiotherapy (SFRT). The purpose of this report is to analyze the results of this strategy over a 5 year period.

Materials and Methods:

In January 2015, two meetings were organized in our department. In the first, data from an audit on the current SFRT rate were shown. In the second, evidence of SFRT efficacy in the relief of pain from uncomplicated bone metastases was presented. In addition, during the weekly discussion of clinical cases, the opportunity to use the SFRT was systematically recalled. Using our institutional database, all patients treated with radiotherapy for uncomplicated painful bone metastases in the period between 2014 (year considered as a reference) and 2019 were retrieved. Data regarding treatment date (year), radiotherapy fractionation, and tumor, patients, and radiation oncologists characteristics were collected.

Results:

A total of 627 patients were included in the analysis. The rate of patients undergoing SFRT increased from 4.0% in 2014 to 63.5% in 2019 (p < 0.001). At multivariable analysis, the delivery of SFRT was significantly correlated with older patients age (>80 years), lung cancer as the primary tumor, treatment prescribed by a radiation oncologist dedicated to palliative treatments, and treatment date (2014 vs 2015–2019).

Conclusions:

This retrospective single-center analysis showed that a simple but intensive and prolonged departmental education strategy can increase the rate of patients treated with SFRT by nearly 16 times.

Creation of clinical algorithms for decision-making in oncology: an example with dose prescription in radiation oncology

In oncology, decision-making in individual situations is often very complex. To deal with such complexity, people tend to reduce it by relying on their initial intuition. The downside of this intuitive, subjective way of decision-making is that it is prone to cognitive and emotional biases such as overestimating the quality of its judgements or being influenced by one’s current mood. Hence, clinical predictions based on intuition often turn out to be wrong and to be outperformed by statistical predictions. Structuring and objectivizing oncological decision-making may thus overcome some of these issues and have advantages such as avoidance of unwarranted clinical practice variance or error-prevention. Even for uncertain situations with limited medical evidence available or controversies about the best treatment option, structured decision-making approaches like clinical algorithms could outperform intuitive decision-making. However, the idea of such algorithms is not to prescribe the clinician which decision to make nor to abolish medical judgement, but to support physicians in making decisions in a systematic and structured manner. An example for a use-case scenario where such an approach may be feasible is the selection of treatment dose in radiation oncology. In this paper, we will describe how a clinical algorithm for selection of a fractionation scheme for palliative irradiation of bone metastases can be created. We explain which steps in the creation process of a clinical algorithm for supporting decision-making need to be  performed and which challenges and limitations have to be considered.