Dis Manage Health Outcomes 2006; 14 (2): 85-90ORIGINAL RESEARCH ARTICLE 1173-8790/06/0002-0085/$39.95/0

© 2006 Adis Data Information BV. All rights reserved.

Promoting the Implementation of Best-PracticeGuidelines Using a Matrix ToolFocus on Cancer Care

Karen Luxford,1 David Hill2 and Richard Bell3

1 National Breast Cancer Centre, Sydney, New South Wales, Australia2 The Cancer Council Victoria, Melbourne, Victoria, Australia3 Cancer Services, Barwon Health, Geelong, Victoria, Australia

Background/Objectives: Internationally, numerous clinical practice guidelines have been developed andAbstractdisseminated with the intention of improving patient care. Research indicates that to improve practice in accordwith clinical evidence, change is required by individual clinicians and teams of clinicians as well as at anorganizational and policy level. A matrix framework has been developed by the Australian Cancer Network’sGuideline Implementation Steering Committee, using the theory of innovation adoption. The matrix is based onthe characteristics of innovations that favor rapid adoption and wide acceptance. Within this construct, newclinical guidelines are equated to an ‘innovation’. The objective of the present study was to pilot this matrix toolto assess its usefulness for individuals and organizations aiming to develop strategies to promote guidelineimplementation in cancer care.

Methods: The matrix was piloted at a workshop with 50 attendees, primarily colorectal surgeons andoncologists. Six key areas relating to guidelines were included in the matrix: (i) compatibility with currentpractice; (ii) relative advantage over current practice; (iii) observability of outcomes; (iv) trialability; (v) simplic-ity of use; and (vi) perceived barriers. Three examples of guideline recommendations for the management ofcolorectal cancer were used during the pilot, covering evidence about best clinical care and psychosocial support:(i) people with high-risk rectal cancer should be referred for consideration of adjuvant preoperative orpostoperative radiotherapy in a multidisciplinary setting; (ii) people with resected Dukes’ C (i.e. node-positive)colon cancer should be referred for consideration of adjuvant therapy in a multidisciplinary setting; and(iii) psychosocial interventions should be a component of care as they can improve the quality of life in patientswith cancer. After discussion of the guideline examples, the attendees completed matrix tool forms to documenttheir perceptions regarding the consistency of current practice with the example guidelines and barriers topractice change. Quantitative responses were assessed by frequency analysis and qualitative responses wereassessed by thematic analysis.

Results: There was consistency in the perceived views of workshop attendees around the six key areas includedin the matrix. The perceived barriers that were highlighted by the respondents included the lack of availableresources (staff, equipment, and funding); lack of multidisciplinary clinics, referral processes, and access toappropriate services; and lack of knowledge of benefit. Perceived facilitators of change included lead clinicians,consumer advocates, government, service administration, professional colleges, and cancer organizations.

Conclusions: The pilot process indicated that the matrix is a tool that could be of use to groups and individualsaiming to develop targeted change strategies to promote evidence-based practice improvement.

86 Luxford et al.

Background/Objectives A lack of practice change can be observed following thedissemination of even the most well developed, evidence-based,expert-endorsed guidelines for disease management. Considera-In recent decades, there has been an emphasis on the develop-tion of potential barriers to compliance during guideline develop-ment and dissemination of numerous clinical practice guidelinesment and during planning of implementation strategies can en-with the aim of improving practice in accord with current evidencehance the adoption of clinical evidence.about what constitutes best practice. It has been argued that the

Currently, there are few tools available to assist with identify-adoption of evidence-based guidelines is a major factor in achiev-ing barriers to guideline compliance or to assist with planning ofing improvements in healthcare outcomes.implementation strategies for specific practice recommendations.Worldwide, approximately 11 million people are diagnosedIt is recognized that individual clinicians and health sector organi-with cancer each year,[1] representing an increasing burden ofzations often seem ‘powerless to act’ and are seeking practicaldisease that could benefit from improved prevention, diagnosis,approaches to improve healthcare delivery.[21]

treatment, and supportive care. In Australia, the development ofWith the aim of providing practical assistance, the Australianguidelines has been led by the field of oncology, with evidence-

Cancer Network’s Guideline Implementation Steering Committeebased guidelines for cancer management in the areas of breast,developed a matrix framework designed to help stakeholders toovarian, colorectal, and lung cancer, amongst others.[2-5] Reflect-identify barriers and enablers for compliance with specific clinicaling international experiences, the findings of several Australianpractice recommendations. This matrix draws on the theory ofsurveys[6,7] indicate that current care is not fully in accord withdiffusion of innovations developed by Rogers,[22,23] which focusesbest-practice recommendations and that there is a need to changeon conditions that are likely to increase or decrease the adoption ofpractice to improve care.a new idea, product, or practice by the members of a given culture.

Most of the tools that are currently available to assist inThis theoretical framework has been acknowledged as useful for

promoting the uptake of evidence have focused on evidence syn-considering the adoption of new clinical practices.[24] For the

thesis and the development of guideline recommendations (e.g. thepurpose of developing the matrix tool, new practice guidelines

AGREE [Appraisal of Guidelines, Research and Evaluation] Col-have been equated to an ‘innovation’ as guidelines can be viewed

laboration)[8,9] rather than the implementation of guidelines.as a ‘practice that is perceived to be new by an individual or other

There is also a recognized need for evidence-based implemen- unit of adoption’.[23]

tation of evidence-based medicine; that is, a need to assess the The matrix is based around five characteristics of innovationseffectiveness of strategies to promote practice compliance.[10,11]

that Rogers identified as favoring rapid adoption: (i) compatibilityMost research aimed at encouraging evidence-based care has (with current practice, values, and needs); (ii) relative advantage

focused on addressing clinician factors, such as improving atti- (over current practice); (iii) complexity (difficulty/simplicity oftudes towards guidelines and improving professional perform- use); (iv) trialability (limited testing to explore process and out-ance.[12,13] There is growing evidence, however, that system comes); and (v) observability (visibility of outcomes within theproblems with health service delivery, such as the waiting time for clinical community). For our purposes, we have added a sixthtest results, are likely to be significant barriers to best practice.[14] category: identifying specific ‘perceived barriers’ because barriers

can present ‘hurdles’ preventing adoption of new guidelines. AnAlthough the process of disseminating clinical practice guide-outline of the matrix tool is provided in table I, indicating the areaslines to the intended audience can produce a small positive effectand issues covered.on best practice,[15,16] research indicates that the most effective

The draft guidelines that were chosen had been widely circulat-implementation strategies are aimed at redressing barriers to bested and reviewed and represented current evidence-based practice.practice, and such strategies target not only clinician behaviorTheir use was intended to assist with future planning for imple-change but also organizational, systems, and policy change.[17-19]

mentation of a set of recommendations nearing completion.While educational strategies have some impact, they alone areinsufficient to effect the changes in health service delivery that areneeded to improve evidence-based practice.[12] Health service Methodsdelivery or structural factors, such as the characteristics and cul-ture of the practice setting, incentives, and regulations,[20] affect The matrix tool was piloted at a workshop with 50 attendees,the ability to provide evidence-based care. including colorectal surgeons (48%), oncologists (32%), and

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Promoting Guideline Implementation Using a Matrix Tool 87

1. People with high-risk rectal cancer should be referred forconsideration of adjuvant preoperative or postoperative radiother-apy in a multidisciplinary setting.

2. People with resected Dukes’ C (i.e. node-positive) colon cancershould be referred for consideration of adjuvant therapy in amultidisciplinary setting.

3. Psychosocial interventions should be a component of care asthey can improve the quality of life in patients with cancer.

At the end of the workshop, the breakout groups reported backto all attendees about the overall outcomes of discussions withintheir groups. Matrix tool forms were completed by all attendeesanonymously (although the respondents’ professions were docu-mented on the forms) and the forms were collected for analysis.

Frequency analysis was undertaken for quantitative responsesand thematic analysis was conducted on qualitative responses.

Results

Of the 50 workshop attendees, 48 provided written responses tothe piloting of the matrix tool. The degree of perceived consisten-cy of current practice with the guideline examples varied depend-ing on the guideline recommendation (table II). While perceptionswere consistent for the guideline relating to psychosocial interven-tions (i.e. current practice was perceived by all respondents as notbeing in accord with the recommendation), responses were mixedfor the other two recommendations. Within each guideline exam-ple, there was consistency among respondents about perceivedreasons as to why care was not in accord with the guideline.

When asked how much the various ‘players’ would have tochange to implement each recommendation, the respondents indi-

Table I. The matrix framework developed by the Australian Cancer Net-work’s Guideline Implementation Steering Committeea

Compatibility with current practice

Is current care consistent with the guideline recommendation?

If not, how not?

Known or presumed reasons why not?

Who needs to change most for practice to be compliant?

Relative advantage over current practice

If the recommendation was applied in practice:

What are the advantages/disadvantages for patients?

What are the advantages/disadvantages for clinicians?

What are the advantages/disadvantages for others in the healthsystem?

Simplicity of use

How easy/difficult would it be to follow the recommendation for differentclinical professions?

Perceived enablers/facilitators of compliance?

Who could take a lead role in facilitating change?

Trialability

How could this recommendation be ‘tried out’ on a limited basis?

Who could make it happen?

Observability of outcomes

How could outcomes of recommendation uptake be fed back toclinicians?

Who could make it happen?

Perceived barriers

Barriers to use of recommendation? (individual/organizational/policy)

Who could help to overcome the barriers?

a The matrix is designed to help stakeholders to identify barriers andenablers for compliance with specific clinical practicerecommendations.

cated the need for major change on the part of the followingothers (20%) such as general surgeons, gastroenterologists, policy groups:

• radiotherapy in a multidisciplinary setting: mostly nonclinicalmakers, and psychologists. The attendees were voluntary membersgroups (government/policy, senior service administration, andof the Colorectal Group of the Victorian Cooperative Oncologyhealth funders)

Group. They were provided with an overview of the aims of the• adjuvant therapy in a multidisciplinary setting: clinicians and

workshop and the theoretical basis of the matrix tool.nonclinical groups

Three examples of guideline recommendations for the manage- • psychosocial interventions: mostly nonclinical groups (govern-ment of colorectal cancer were used during the pilot, covering ment/policy, senior service administration, and health funders).

When considering the relative advantage or disadvantage ofevidence about best clinical care and psychosocial support. Theguideline implementation over current practice (table III), theguideline examples were selected in areas known or perceived asrespondents consistently perceived the main advantage to patientscurrent gaps in evidence-based care. Each guideline was consid-as being improved outcomes. The respondents also considered

ered by a separate breakout group of, on average, 16 attendeesimproved patient outcomes and patient satisfaction as being the

from a range of disciplines. main advantages to themselves as clinicians in terms of their ownThe three guideline examples piloted were: job satisfaction. The perceived disadvantages to either patients or

© 2006 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2006; 14 (2)

88 Luxford et al.

clinicians of implementing the adjuvant therapy guidelines were nary care could be specifically tested by reviewing existing mod-split between treatment-related issues (e.g. adverse effects for els already established for other cancers. Regarding the ‘ob-patients or increased workload for clinicians) and issues relating to servability of outcomes’, the respondents indicated that feedbackdelivery of care in a multidisciplinary setting (e.g. confusion about to clinicians should be provided by undertaking and reportingthe identity of the primary carer for the patient or loss of autonomy audits of care outcomes (e.g. recurrence rates, quality-of-life out-in decision-making for the clinician). comes, patient satisfaction surveys) and that the findings of such

audits should also be disseminated through journals and confer-The majority of respondents considered guideline exampleences.numbers 1 (radiotherapy for high-risk rectal cancer in a multidis-

When considering the perceived barriers to provision of care inciplinary setting) and 3 (psychosocial interventions) as beingaccord with the guidelines, the respondents highlighted the lack ofdifficult recommendations to follow (73% and 64%, respectively).available resources (staff, equipment, and funding), multidiscipli-Adjuvant therapy for node-positive cancer in a multidisciplinarynary clinics, referral processes, and access to appropriate services.setting was considered easy to implement by 57% of respondents.On an individual level, clinicians’ attitudes and their lack ofRespondents reported that the factors that could facilitateknowledge about evidence of benefit, as well as patients’ choiceschange included funding of multidisciplinary care, provision ofof therapies, were considered barriers to guideline compliance.further staffing resources, increased access to therapy (e.g. radio-

therapy) and education of patients and clinicians about benefits(e.g. promotion of awareness of psychosocial care). Perceived Discussionfacilitators of change included lead clinicians, consumer advo-cates, government, service administration, professional colleges, The piloting of the matrix tool identified consistent views of aand cancer organizations. range of stakeholders in guideline implementation across each of

Respondents reported that the ‘trialability’ of the guidelines the six main areas investigated by the tool. Although there werecould be tested by establishing piloting sites and that multidiscipli- consistent views about the reasons as to why current practice was

Table II. Perception of compatibility of three examples of guideline recommendations with current practice, according to a group of attendees at aworkshop piloting a matrix tool to promote guideline implementationa

Guideline example Number of attendees Number of attendees Ways in which care is not Presumed reasons forperceiving care to perceiving care to not consistent inconsistencybe consistent with be consistent withrecommendation recommendation

People with high-risk rectal 8 9 Lack of referral; lack of Availability of radiotherapy;cancer should be referred for services; lone decision- patient concern aboutconsideration of adjuvant making (patient, clinician) treatment; lack ofpreoperative or postoperative multidisciplinary care clinics;radiotherapy in a multidisciplinary lack of understanding aboutsetting (n = 17) ‘high risk’ definition

People with resected Dukes’ C 11 4 Lack of multidisciplinary Lack of knowledge about(node-positive) colon cancer care meetings; some benefit on the part ofshould be referred for evidence of low referral clinicians and patients; lackconsideration of adjuvant rates of multidisciplinary caretherapy in a multidisciplinary clinics; fear of toxicity;setting (n = 15) patient choice

Psychosocial interventions 0 16 (including 1 ‘uncertain’) Limited psychosocial Limited resources; lack ofshould be a component of care as resources; psychosocial time; not recognized as athey can improve the quality of life intervention not considered patient ‘need’; lack ofin patients with cancer (n = 16) by doctors knowledge of benefit; lack of

referral system

a Attendees included colorectal surgeons, oncologists, and others (including general surgeons, gastroenterologists, policy makers, andpsychologists).

n = number of attendees discussing each guideline example.

© 2006 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2006; 14 (2)

Promoting Guideline Implementation Using a Matrix Tool 89

Table III. Perceptions about relative advantage/disadvantage of three examples of guideline recommendations over current practice, according to a groupof attendees at a workshop piloting a matrix tool to promote guideline implementationa

Guideline example Advantages for patients Disadvantages for patients Advantages for clinicians Disadvantages for clinicians

People with high-risk rectal Improved patient outcomes Treatment-related adverse Improved patient outcomes Increased workload; need tocancer should be referred for (e.g. decreased recurrence, effects; increased treatment (job satisfaction); financial manage toxicity; decreasedconsideration of adjuvant increased survival) time course; more travel to benefit to oncologists; surgeon contact with patientpreoperative or postoperative receive treatment; confusion improved surgeryradiotherapy in a about identity of primary schedulingmultidisciplinary setting carer

People with resected Dukes’ Improved patient outcomes Treatment-related adverse Improved patient outcomes Increased workload; loss ofC (node-positive) colon (e.g. decreased recurrence, effects; perceived loss of (job satisfaction); financial autonomy in decision-makingcancer should be referred for increased survival) one-on-one doctor-patient benefit to oncologists;consideration of adjuvant relationships improved communicationstherapy in a multidisciplinary between clinicianssetting

Psychosocial interventions Improved patient outcomes Cost to patient Improved patient Increased time spentshould be a component of (e.g. quality of life) satisfaction; better patientcare as they can improve the compliance with treatmentquality of life in patients withcancer

a Attendees included colorectal surgeons, oncologists, and others (including general surgeons, gastroenterologists, policy makers, andpsychologists).

not thought to be in accord with guidelines, perceptions about the A potential limitation of the matrix tool is that it focuses onstakeholder perceptions (e.g. perceptions of current practice) rath-compatibility of the guidelines with current practice were incon-er than actual care. However, the tool is intended to investigate thesistent for two of the guideline examples. Inconsistencies in theviews of key groups such as clinicians and service providersresponses relating to guideline example numbers 1 and 2 appearedwithin an industry-developed framework of the theory of innova-to be due to the fact that these guidelines each covered two issues –tion diffusion.the type of treatment and the setting of multidisciplinary planning

Subsequent to the pilot using the colorectal cancer guideline– and different respondents may have been considering differentexamples, the matrix tool has been used in a similar workshopparts of the guidelines when commenting on their compatibilitydesigned to help tailor implementation strategies for the Australianwith current practice.guidelines for management of ovarian cancer. As a result of usingIt is interesting to note that respondents perceived improvedthe tool, a specific strategy promoting the appropriate referral ofpatient outcomes and patient satisfaction as being the main advan-symptomatic women by general practitioners is being undertakentage of best practice not only for patients but also for the treatingby the National Ovarian Cancer Program of the National Breast

clinicians. This suggests that an important strategy for promotingCancer Centre. The matrix tool has provided a practical frame-

best practice is to highlight to clinicians the benefits to patients ofwork for structuring implementation plans for specific guidelines

delivering care in accord with guidelines.within a particular setting.

The tool proved useful in helping to identify stakeholder views

about barriers to best practice and the groups and individuals who Conclusionswere considered useful facilitators of future change. The barriers

identified in this study overlap with some of the barriers identified There are currently few tools available to assist with identifica-in a review of physician guideline adherence by Cabana et al.[25] tion of barriers to guideline compliance or with planning strategiesHowever, Cabana et al.[25] concluded that such studies may not be for promoting the uptake of specific practice recommendations.generalizable “since barriers in one setting may not be present in The matrix tool investigated in the current study could be used at aanother.” This supports the need to investigate barriers and en- unit level by individual clinicians or at a system-wide level byablers within a specific context and to develop implementation healthcare services or health organizations planning strategies tostrategies tailored for specific guideline recommendations. promote best practice. Although the use of the matrix to date has

© 2006 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2006; 14 (2)

90 Luxford et al.

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14. Ellrodt AG, Conner L, Riedinger M, et al. Measuring and improving physiciancompliance with clinical practice guidelines. Ann Intern Med 1995; 122:

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15. Grimshaw JM, Thomas RE, MacLennan, et al. Effectiveness and efficiency ofguideline dissemination and implementation strategies. Health Technol Assess

We would like to thank the Colorectal Group of the Victorian Cooperative2004; 8 (6): 1-85

Oncology Group for piloting the matrix tool, and Susan Fitzpatrick (The16. Grimshaw JM, Eccles MP. Is evidence-based implementation of evidence-basedCancer Council Victoria) and Fiona Booth (National Breast Cancer Centre)

care possible? Med J Aust 2004; 180: S50-1for assistance with collation of the resultant data.

17. Moss F, Garside P, Dawson S. Organisational change: key to quality improvement.The authors did not receive any funding to assist with preparation of thisQual Health Care 1998; 7 Suppl.: S1-2

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About the Author: Dr Karen Luxford is Deputy Director of the National8. AGREE Collaboration. Development and validation of an international appraisalBreast Cancer Centre (Sydney, NSW, Australia). She has managed a num-instrument for assessing the quality of clinical practice guidelines: the AGREE

project. Qual Saf Health Care 2003; 12: 18-23 ber of large national programs in health service improvement and consum-9. Vlayen J, Aertgeerts B, Hannes K, et al. A systematic review of appraisal tools for er support and has a research interest in the implementation of evidence-

clinical practice guidelines: multiple similarities and one common deficit. Int J based best practice.Qual Health Care 2005 Jun; 17 (3): 235-42

Correspondence and offprints: Dr Karen Luxford, National Breast Cancer10. Grol R. Beliefs and evidence in changing clinical practice. BMJ 1997; 315: 418-21Centre, Locked Bag 15, Camperdown, NSW 1450, Australia.11. Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine.

Jt Comm J Qual Improv 1999; 25: 503-21 E-mail: karen.luxford@nbcc.org.au

© 2006 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2006; 14 (2)