How do clinicians use implementation tools to apply breast cancer screening guidelines to practice?

Abstract

Background: Implementation tools (iTools) may enhance uptake of guidelines. However, little evidence exists on their use by primary care clinicians. This study explored which iTools clinicians used and how often; how satisfied clinicians were with the tools; whether tool use was associated with practice changes; and identified mediators for practice change(s) related to breast cancer screening (BCS).

Methods: Canadian primary care providers who are members of the Practice-Based Small Group Learning Program (n = 1464) were invited to participate in this mixed methods study. An educational module was discussed in a small group learning context, and data collection included an on-line survey, practice reflection tools (PRTs), and interviews. The module included both the Canadian Task Force on Preventive Health Care revised guideline on BCS and iTools for clinician and/or patient use. After discussing the module and at 3 months, participants completed PRTs identifying their planned practice change(s) and documenting implementation outcome(s). Use of the iTools was explored via online survey and individual interviews.

Results: Seventy participants agreed to participate. Of these, 48 participated in the online survey, 43 completed PRTs and 14 were interviewed. Most survey participants (77%) reported using at least one of seven tools available for implementing BCS guideline. Of these (78%) reported using more than one tool. Almost all participants used tools for clinicians (92%) and 62% also used tools for patients. As more tools were used, more practice changes were reported on the survey and PRTs. Interviews provided additional findings. Once information from an iTool was internalized, there was no further need for the tool. Participants did not use tools (23%) due to disagreements with the BCS guideline, patients' expectations, and/or experiences with diagnosis of breast cancer.

Conclusion: This study found that clinicians use tools to implement practice changes related to BCS guideline. Tools developed for clinicians were used to understand and consolidate the recommendations before tools to be used with patients were employed to promote decision-making. Mediating factors that impacted tool use confirmed previous research. Finally, use of some iTools decreased over time because information was internalized.

Keywords: Breast cancer screening; Clinical practice guidelines; Guideline implementation; Implementation strategy; Implementation tools.

Fig. 1

Overview of mixed methodology approach to study how clinicians use implementation tools. CTC = commitment to change; PBSG = practice-based small group; PRT = practice reflection tool; QUAL = qualitative; QUAN = quantitative; a-see Additional file 1; b-see Additional file 2; c-see Additional file 3; d-see Additional file 4

Fig. 2

Flowchart showing the solicitation and recruitment efforts for the study. FMPE = The Foundation for Medical Practice Education; PBSG = practice-based small groups; BCS module = Breast Cancer Screening module

Fig. 3

Summary of implementation tool used. Percent of survey participants (n = 37) who used the various breast cancer screening tools provided or referenced in the Breast Cancer Screening module. The description of each tool can be found in Table 1. Note: numbers do not total 100% as more than one tool could be selected

Fig. 4

Relationship between tool use and self-reported practice change. Data is shown for those that reported having made a change prior to study (already changed), made at least one practice change (made change), and those that did not make a change (no change)