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Table 5 Details of barrier domains, barriers, proposed intuitive interventions, proposed theory-based interventions, and matched behaviour change techniques

From: Using behaviour change and implementation science to address low referral rates in oncology

Barrier Domain Description of actual barrier Proposed intuitive interventions Proposed theory-based interventions Details of final Intervention Strategy (Progress: Not adopted (NA); Not yet started (NS); In progress (P); Completed (C); Ongoing (O) Behaviour Change Technique (BCT)
Environmental context and resources
Staff perceptions include: the system is not good enough/the necessary resources/verbal and written communication are not adequate to ensure high risk patients are referred.
Paper FCC referral forms not always available in clinic; faxing process can be fraught; multiple electronic management systems being used across hospitals and departments with limited connectivity. Concerted effort be made to restock paper referral forms in the clinics [Log]
Write a letter as a referral to overcome problem of unavailable forms [Log]
Put the referral forms on Hospital B’s electronic patient management system [Log]
Put the referral forms on both Hospitals’ respective electronic patient management systems [Focus groups]
Enable emailed referrals for those clinicians who have the form template but do not have access to the hospital’s electronic patient management system. Forms are currently faxed. [Focus groups]
Genetic staff and data managers to put referral forms on each hospital’s electronic patient management system and optimise known limited interoperability with FCC database. (P)
Add an email address to paper or printable versions of forms. Replace printable form on hospital forms site and email to private referrers with explanation of changes. (C)
Genetic staff to develop protocol for retrieving referrals, adding patient details to genetic database (different from the oncology database), triaging and booking appointments. (C)
Genetic staff and referring clinicians to develop documenting regimes to: allow treating team to track referral progress, and to record if patients decline or defer an appointment. (P)
Use colorectal group email, and oncology department and multidisciplinary team meetings to disseminate information about how to refer on each system and where to look for pending or completed appointments. (O)
Adding objects to the environment; Instruction on how to perform the behaviour
Adding objects to the environment; Instruction on how to perform behaviour
Self-monitoring of outcomes of behaviour
Adding objects to the environment; Restructuring the physical environment; Social support (practical)
Instruction on how to perform the behaviour; Credible source
Referral forms are not seen as flexible enough Forms were easy to fill out (check the box) but more room was needed to explain atypical presentations. [Interview]   Genetic staff and referring clinicians to review content of referral forms and include a larger free text box for referrals that do not meet the tick box criteria (C) Restructuring the physical environment;
Adding objects to the environment;
Reflex secondary testing (BRAF V600E testing for MLH1 abnormal specimens) has been agreed in principle by pathology department but implementation of in-house testing is delayed   Of all the high risk IHC results, ones involving abnormal MLH1 were the most likely to not be followed up. [Audit] Pathology department to develop a departmental protocol to automatically send MLH1 abnormal specimens to outside pathology services for BRAF V600E testing. (C)
Until this happens, treating team to order BRAF V600E testing. Instructions and reminders to be given at CRC meetings by genetic and pathology staff. (C)
Adding objects to the environment; Conserve mental resources
Instruction on how to perform the behaviour; Social support (practical); Cues and prompts
Pathology and hereditary cancer representatives provide valuable expertise on appropriate referrals to multidisciplinary team meetings (case conferences) but are not always available for meeting at Hospital B. Patient information is not always made available before the meetings.   Change the time of the multidisciplinary meeting at Hospital B to a time when pathology and genetic service representatives could attend [Focus group] Changing the time of the Multidisciplinary meeting was investigated but deemed not feasible. (NA)
Multidisciplinary team coordinator to add a genetics field to the patient information template circulated before the meeting and remind clinicians presenting patients that each field needs to be discussed. If pathology and genetic representatives are unable to attend the meeting they can review this information that is circulated before the meeting and flag issues for the chairperson to raise (P)
Social support (practical); cues and prompts
Skills and knowledge
Staff perceptions include: training is not adequate/ offered regularly enough; lack of awareness about/ agreement with/ understanding about/the guidelines
Surgical teams may not be familiar with latest referral guidelines   Ensure surgeons are included in education around hereditary cancer referral criteria updates [Focus groups] Presentation to Surgical Grand Rounds on best practice in referral for patients flagged as having a high risk of Lynch Syndrome. (C) Credible source; Information about health consequences
Rotating staff may not be familiar with the referral process. Currently training is ad hoc   A session on how to explain hereditary cancer risk to patients, how to refer, and how to interpret results to be offered to rotating staff [Focus group] Quarterly workshops for new surgical and oncology Medical Officers on Hereditary Cancer including pathology and referral processes to be established. (O) Instruction on how to perform the behaviour; Credible source; Information about health consequences
Supplementary testing for patients with MLH1 abnormalities was not routinely being ordered by treating clinicians/not yet initiated by pathology meaning patients were missed   Feedback of audit results showing that these patients were the largest group not receiving appropriate action Feedback of audit results to key treating clinicians with genetic and pathology specialists in attendance to highlight the number of patients missing appropriate supplementary testing. Explanation of how to order and interpret BRAF V600E testing. (C) Feedback on outcome of behaviour; instruction on how to perform the behaviour; credible source
Oncology nurses have a role to play in helping identify patients with high risk family history, but are unsure of criteria. This recognises that family history is often not disclosed to the admitting officer but emerges later as the patient discusses it with his or her family. Nurses are the usual people who are told this additional information. The nurses in one area were trained to recognise and pass on new relevant information disclosed by the patient, to the medical team. This should be replicated in other areas [Log] Oncology nurses and allied health (social worker/counsellor, physiotherapists, occupational therapists, etc) to be provided with a training session In-service education (30 mins with Powerpoint slides and a summary handout) for nursing and allied health staff. Objectives: to provide information about Lynch syndrome and accompanying increased cancer risks, to clarify what family history is relevant and what not, and how to communicate this information to the treating team or genetic service advocate. (C) Information about health consequences; Credible source;
Beliefs about capabilities
Staff do not find it easy/have previously encountered problems when trying to refer
Terminology in the pathology reports can be confusing to clinicians, pathologists and geneticists, generating the perception that it is hard to make an appropriate referral. Currently a mix of terms used: “positive/negative,” “abnormal/normal,” “preserved/lost” Wording on the reports to be simplified and standardised [Log] Wording on the reports to be simplified and standardised following the Royal Australian College of Pathologists’ recommended wording [Log] Wording for IHC and BRAF V600E pathology reporting to be simplified and standardised following the Royal Australian College of Pathologists’ recommended wording to make results easier to interpret. (C) Instruction on how to perform the behaviour;
Credible source; Conserve mental resources
Memory, attention and decision making processes
Staff perceptions include: not having referral as habitual practice/having justifiable reasons for not referring
Interpreting pathology results can be difficult, making the decision-making process more difficult and less routine   Small posters giving information about how to interpret IHC results to be put up in the clinics where patients come for follow-up [Focus groups] Information sheets on how to interpret and act on IHC /BRAF V600E results for the surgical and oncology clinics where patients come for follow-up. (NS)
[Not supported at Hospital B]
Instruction on how to perform the behaviour; Credible source; Prompts or cues
A number of factors mean that referrals may be overlooked: e.g. IHC reports not available at patients’ first follow-up, competing priorities in limited consult time, delay (with potential to not follow up) e.g., when clinical judgement says patient is overwhelmed, or seriously ill and is unable to discuss a genetic referral Document in the patient’s notes when a referral is postponed so it can be addressed next consult [Log] Use a template that includes a genetics field for when patients are presented at case conference or for letters to external health providers [Focus groups and interviews] Incorporation of IHC results and genetic referrals (or pending referrals) to be included routinely in correspondence from multidisciplinary case conferences to patients’ external healthcare providers. (P)
Use a checklist or documentation protocol for follow up consultations to ensure that when genetic referrals are not addressed post-operatively for whatever reason, they are not overlooked or forgotten entirely. Checklist being introduced by one team for follow up consults. (P)
Prompts or cues; Social support (practical); Credible source
Prompts or cues; Social support (practical)
  1. Unless specified, interventions were department wide, involving both hospitals’ oncology, FCC and/or pathology departments