Table 1 Overview of the coding frame with main categories and their subcategories
Main Categories | Subcategories | Quotes |
|---|---|---|
Elements of the implementation perceived as successful/non-successful (3.1) | Informational meetings | “So I have to say that I see what you have said [during the informational meeting]as a very positive contribution towards me making better assessments of what are necessary examinations for my patients” |
Digital access to the guideline | “I mean it is NEL we mostly use, and many of the guidelines are incorporated there.” | |
Physical copy of the short version of the guideline | “I had it for a while too, but things like these, they disappear.” | |
Perceived changes, or lack of changes, in practice after the implementation (3.2) | Changes in use of the guideline | “I have used it a little, to show patients that there is actually a cost for us to perform diagnostic imaging. Or make an assessment of when to perform diagnostic imaging or not” |
Changes in referral pattern | In general the number of x-rays we perform have decreased lately, but if you go to [private institution] I don’t think you will see the same trend there” | |
Changes in justification and quality of referrals | “[…]where I may still refer to unnecessary MRI examinations of the shoulders and things like that, where the examination wont give much […]” | |
Changes in communication between primary and secondary care | “But the answers with the results [of the examination]is as before, there is no increase in feedback or anything like that” | |
Changes in communication with Norwegian labor and welfare administration | “But the problem is more that NAV generally has a high demand towards us to refer to examinations, and our clinical examination is not enough for them.” | |
Environment related factors affecting guideline use and adherence (3.3) | Organization and placement of responsibility | “So we don’t have a regulatory body, and the way the system works today there isn’t any possibility to have a regulatory body for x-ray referrals either.” |
Lack of forum for direct communication | “No, that’s difficult since we don’t have a system where we can give this kind of feedback without rejecting the referral completely” | |
Patient as a customer | “You have so much power as a patient today, for a referrer…You can rate them [the referring GPs] by how happy you are, and those reviews are public online…” | |
Private actors in the radiological field | “Well that is what is being advertised by some private actors. Make sure you are healthy”. | |
Public media attention | “So the patients will see so much scare mongering in the media, especially [tabloids]. | |
User related factors affecting guideline use and adherence (3.4) | Professional autonomy | “After all, that’s what clinical judgement is in primary care, to deviate from guidelines and touch and clinically assess the patient” |
Complexity of the decision-making process | “It’s not just that knee in a way, you have to consider the entire person with their medical and family history […] and situations like that is what makes you deviate from the guidelines.” | |
Atitudes toward guidelines | “But it hasn’t been any focus on [the guideline] from the higher ups anyway. We may not be that good at referring to these kind of guidelines in general.” |