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The effectiveness of clinical guideline implementation strategies in oncology—a systematic review

Abstract

Importance

Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.

Objective

This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.

Methods

A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.

Findings

Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.

Patient-level

Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.

Provider-level

Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

Conclusions and relevance

Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Peer Review reports

Key points

Question: What are the most effective clinical guideline implementation strategies in oncology?

Findings: The nine included studies assessed multi-component guideline implementation interventions compared to no intervention. Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain. Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

Meaning: This systematic review gives an overview of recent strategies used for guideline implementation in oncology in order to inform policymakers and professional organisations on the development and adoption of implementation strategies.

Introduction

Clinical practice guidelines (CPGs) are a powerful tool of evidence-based medicine, designed to mitigate the gap between clinical research and current practice [1, 2]. It was shown that non-adherence to guidelines may lead to unnecessary diagnostics and suboptimal treatment [3,4,5]. On the contrary, a systematic review concluded that adherence to breast cancer guidelines was associated with increased overall survival and disease-free survival [6]. The implementation of CPGs in oncology is considered to be very complex and therefore challenging due to the heterogeneity of cancer types, high number of CPGs of different methodologies, inconsistent use of guideline-based quality indicators, complexity of therapeutic decisions, and the various influences of multiple interconnected clinical specialties involved in this setting [7, 8]. This may lead to inconsistencies and patient and practitioner confusion due to information overload [9, 10]. Also, the heterogeneity in structure, target groups and endpoints addressed in guidelines may be a challenge for implementation, as discovered by comparing nine oncological CPGs of well-known organisations on advanced breast, lung, and colon cancer [11]. Due to these barriers, recommendations may not be adequately applied in practice and patients may not benefit from evidence-based research. The use of CPGs in practice is reported as being unpredictable and slow [12]. It was estimated that approximately 30–50% of patients receive treatment that is not evidence-based, and 20–25% receive unnecessary or even potentially harmful treatments [13]. For example, a study concluded that guideline-discordant imaging appears to be common as almost half of men with low-risk localised prostate cancer receive unnecessary imaging while there is underuse of imaging among men with a high-risk disease in the USA [14]. Furthermore, it was shown that nurses' failure to routinely screen and implement appropriate cancer pain management has an adverse impact on health-related quality of life [15]. Moreover, another study showed that urgent referral guideline recommendations were not followed for the majority of patients with common possible cancer features in the UK [4]. Consequently, the development of high methodological CPGs alone does not automatically result in their use. In order to improve patient outcomes and decrease variations in the current oncological practice, it is important to identify and assess optimal strategies for the implementation of CPGs [6, 7, 16].

There are various implementation strategies that have been tested over the years. These strategies can be used alone as single-component strategies or in combination as multi-component interventions to facilitate the use of CPGs in clinical practice. The dissemination of printed educational materials has been considered as accessible, convenient to use, and potentially cost-effective intervention across healthcare settings [17]. It was shown that used alone and compared to no intervention, it may have a small beneficial effect on professional practice outcomes. The effect of opinion leaders was examined in a recent Cochrane review which concluded that used alone or in combination with other implementation strategies, it probably improves the compliance with evidence-based practice of professionals [18]. Further, reminders (manually and computer-generated) were shown to probably improve the quality of care compared to usual care or other co-interventions [19, 20]. Moreover, it was shown that audit and feedback lead to small but potentially important improvements in professional practice. The effectiveness of guideline implementation strategies seems to depend on how the feedback is provided and on the baseline performance of professionals [21].

The systematic review of Grimshaw 2004 found that 73% of the included studies examined multi-component interventions, and the most effective single strategies were reminders, dissemination of educational materials, and audit and feedback [22]. In the hospital setting of emergency departments, reminders alone or educational interventions combined with audit and feedback were likely to be effective in improving guideline adherence [23]. In the care of chronic diseases at the primary level setting, passively receiving educational materials was least effective compared to educational meetings implying the active involvement of professionals [24]. Multi-component interventions were slightly more effective compared to single interventions [24, 25]. Still, in all these reviews, although assessing change in health care provider behaviours, it was rather uncertain whether the interventions really lead to improved patient outcomes.

One review concluded that reminders and feedback as a single intervention, and group education and organisational strategies used as part of a multi-component intervention, corresponded with positive changes on professionals’ behaviour and patient outcomes in the oncological setting [26]. Still, this review relies mostly on studies published more than ten years ago. Moreover, the research findings from Grimshaw [22] and Hakkennes and Dodd [27] serve as a foundation for understanding CPG implementation strategies among professionals, yet they rely on papers published almost 20 years ago and are not specific to oncology. Other more recent reviews assess the effectiveness of implementation strategies, however, do not particularly focus on oncology [24, 25].

Despite the current interest in CPGs and innovative methods to promote knowledge transfer into practice, a surprisingly high uncertainty about the effectiveness of guideline implementation strategies in oncology remains. This systematic review aims to fill the gap regarding the synthesis of the effectiveness of recent guideline implementation strategies on patient-relevant outcomes and guideline adherence of healthcare professionals in the oncological settings.

Methods

This systematic review was performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [28, 29]. The PICO (Population, Intervention, Comparison, Outcome) framework was used to guide the eligibility criteria of this review (Table 1). To identify most recent studies, a comprehensive electronic literature search for studies as of year 2011 was performed. The following electronic databases were searched on 16 December 2022: PubMed, Web of Science, GIN, CENTRAL and CINAHL. With the assistance of an experienced information specialist (IM), these search strategies were optimised. Search filters were used to identify papers with study designs of interest (e.g. filter for RCTs). The search strategies included keywords such as clinical practice guideline, implementation, survival, adherence, behaviour, health professionals, patients, oncology. The full search strategies can be found in Additional file 1 in the Supplement of this review.

Table 1 PICO framework

Screening and selection of studies were performed independently by two reviewers (AB, VP, NK). Reference lists of all eligible studies and relevant systematic reviews were hand searched by one author (AB) for additional eligible studies. Only prospectively registered controlled studies (e.g. (cluster) randomized controlled trials, controlled pre-post trial designs) were included in this review. The risk of bias of each included study was independently assessed by pairs of two reviewers (AB, VP, AW, NK). Disagreements were resolved by discussion and consensus and a third reviewer (NS) was involved when consensus was not reached. The Cochrane risk of bias tool for RCTs quality assessment and ROBINS-tool for non-randomized studies were used [3031]. Overall, a study was judged to have a high risk of bias if at least one bias domain was judged to be at high risk. Moreover, the certainty in the evidence was rated for all outcomes using the GRADE tool [32] and recommendations [33]. It was judged by one reviewer (AB) and checked by two other reviewers (NK, NS). The assessment was separated according to the study design.

Results

A total of 1326 records were identified through electronic database searching. After identifying nine additional records through hand-searching references and removing fifteen duplicate records, a total of 1320 records were included for the title and abstract screening. The detailed study selection process is described in the PRISMA flow-diagram (Fig. 1). Furthermore, the list of excluded studies at full-text screening stage can be found in the Supplement (Additional file 2). A total of nine studies published between 2017 and 2022, five cluster RCTs [34,35,36,37,38] and four controlled NRSIs with before-and after study design [39,40,41,42], were included in the synthesis. Further, six randomized ongoing trials were identified [43,44,45,46,47,48] and seven studies were categorised as awaiting classification due to no published results [49,50,51] and conference abstracts with insufficient information [52,53,54] or inaccessible full text [55].

Fig. 1
figure 1

PRISMA flowchart. RCT = randomized controlled trial; NRSIs = non-randomized studies of interventions

The nine included studies assessed multi-component guideline implementation interventions compared to no intervention in 3577 cancer patients and more than 450 oncologists, nurses and medical staff [34,35,36,37,38,39,40,41,42]. The most frequently used strategies, which were applied in all nine interventions, were educational meetings and educational materials (Table 2). Population characteristics of the included studies, a detailed description of the interventions, outcomes and characteristics of ongoing and awaiting assessment studies can be found in the Supplement (Additional files 3, 4,5, 6, 7).

Table 2 Study characteristics, interventions and comparators

Risk of bias in randomized studies

Overall, the risk of bias was rated as high for all five cluster RCTs [34,35,36,37,38] due to the lack of blinding of outcome assessors and participants, which affected both objective and subjective outcomes (Fig. 2). Additionally, the detailed risk of bias judgement table and the risk of bias summary plot are listed in Additional files 8 and 10 in the Supplement.

Fig. 2
figure 2

Risk of bias in randomized controlled trials

Risk of bias in non-randomized studies

For both objective and subjective outcomes, the overall risk of bias was judged to be serious in three studies (studies have some important problems) [40,41,42] and critical in one study (the study is too problematic to provide any useful evidence and should not be included in synthesis) [39] (Fig. 3). This due to the lack of comparability between groups and lack of control for confounders, bias in the measurement and the reporting of outcomes. Additionally, the detailed risk of bias judgement table and the risk of bias summary plot are listed Additional files 9 and 10 in the Supplement.

Fig. 3
figure 3

Risk of bias in non-randomized controlled trials

Effects on primary (patient-level) and secondary (provider-level) outcomes

The effects on primary and secondary outcomes of this review are summarised in Additional file 11 in the outcome effects Tables 1, 2, 3, 4, 5, 6, 7, 8 in the Supplement of this review.

Patient-level outcomes

Overall survival

Two cluster RCTs reported overall survival in 865 cancer patients [36, 37]. Both studies suggested little to no difference in effects (HR 1.05, 95% CI: 0.85 to 1.29, p = 0.68; RR 0.946, 95% CI: 0.895 to 1.228, p = 0.813; eTable 1) [36, 37]. Overall, the effect of the implementation interventions may have little to no effect on overall survival, still, this is uncertain due to the serious risk of bias and imprecision of outcome measurement.

Quality of life and patient-reported outcomes

One cluster RCT reported pain scores for 544 cancer patients [34]. The intervention combining opinion leaders with educational meetings, materials and audit and feedback may have little to no effect on pain scores and on total quality of life QLQ-C15-PAL scores measured at different follow-up times (eTable 2). The certainty in the evidence is low due to serious limitations in the study design and imprecision.

Two NRSIs reported quality of life as different symptoms measured with different scales in 472 patients [41, 42]. The time points reported in both studies were not clearly described. Measured on a scale from 0 (no pain) to 10 (worst pain), the results of Cowperthwaite 2019 suggested little to no difference between intervention and comparator at T1 (MD 0.090, 95% CI: -0.6131 to 0.7931, p = 0.8013; eTable 2) and a small effect at T2 (MD 0.210, 95% CI: -0.3477 to 0.7677, p = 0.4594; eTable 2) on pain intensity [42]. Still, the evidence is very uncertain. The results of Knoerl 2019 (eTable 2) suggested effects in favour of the intervention on CIPN sensory (at T1, T2, T3) and motor severity (at T1, T3) on a Lickert Scale from 1 to 4 [41], however, the certainty in the evidence is very uncertain. Overall, the effect of the implementation interventions compared to no intervention resulting from non-randomized studies on quality of life is very uncertain due to the very serious risk of bias, imprecision, and serious indirectness of outcome measurement.

Adverse events

Two cluster RCTs reported adverse events in 865 cancer patients [36, 37]. Gilbert 2021 suggested an effect in favour of the comparator regarding the proportion of patients having at least one adverse event or one postsurgical complication (eTable 3), still, the evidence is very uncertain [37]. The results of Mohile 2021 suggested an effect in favour of the intervention at 3 months in terms of 3–5 grade adverse events (adjusted RR 0.74, 95% CI: 0.64 to 0.86, p = 0.001; eTable 3) [36]. Overall, the effect of the implementation interventions may have little to no effect on adverse events, still, the evidence is very uncertain due to the serious risk of bias, imprecision and inconsistency in outcome results.

Provider-level outcomes

Screening

Two cluster RCTs reported screening for 454 cancer patients [35, 37]. Both studies combined educational meetings with educational materials, academic detailing. One study additionally combined opinion leaders with audit and feedback. Both suggested an effect in favour of the intervention (OR 348.82, 95% CI 69.31 to 1755.62, p < 0.0001; RR = 5.29, 95% CI 3.03 to 9.23, p < 0.0001; eTable 4). Overall, the multicomponent interventions implemented in these studies may increase adherence to guidelines regarding screening rates, still, the certainty of the evidence is low due to serious limitations in the study design and imprecision of results.

Referral

Two cluster RCTs reported referrals for 1219 patients [35, 38]. The results of Brown 2018 suggested little to no difference between the intervention (educational meetings, materials, audit and feedback, opinion leaders, tailored intervention) and no intervention on referrals (RR 1.0474, 95% CI: 0.8631 to 1.2711, p = 0.6389; eTable 5) [38]. The results of McCarter 2018 suggested an effect in favour of almost the same intervention (used academic detailing instead of a tailored intervention) on referral rates (OR 37.70, 95% CI: 0.93 to 1530, p = 0.0537; eTable 5) [35]. Overall, the multicomponent interventions implemented in these studies may increase referrals slightly according to guidelines, still, the certainty of the evidence is low due to serious limitations in the study design and serious imprecision.

Prescribing behaviour

One cluster RCT reported this outcome for 718 cancer patients [36]. Combining educational materials and meetings for guideline implementation may increase adherence to guidelines slightly regarding prescribing behaviour compared to no intervention (eTable 6). However, the certainty in the evidence is low due to serious limitations in the study design and serious imprecision.

Two NRSIs reported prescribing behaviour [40, 41]. The results of Bonkowski 2018 suggested effects in favour of the intervention on narcotic administration of one and three doses. Further, the evidence suggested little effect in one item (MD -0.440, 95% CI: -0.0867 to 0.7933, p = 0.0157; eTable 6), and no difference in another item (MD 0.000, 95% CI: -0.3354 to 0.3354, p = 1.000; eTable 6) [40]. Knoerl 2021 suggested an effect in favour of the intervention on the frequency of appropriate mild CIPN management (OR = 2.5278, 95% CI: 0.8356 to 7.6471, p = 0.1006; eTable 6), whereas the frequency for appropriate moderate-severe CIPN management (OR = 0.8571, 95% CI: 0.2463 to 2.9827, p = 0.8086; eTable 6) was lower after the intervention [41]. Overall, the interventions may have little to no effect on this outcome, but the evidence from non-randomized studies is very uncertain due to very serious limitations in the study design and serious imprecision.

Attitudes

Six included studies reported this outcome using different measurements (eTable 11) [35, 38,39,40,41,42]. One RCT and one NRSI reported attitudes combined with knowledge [38, 42]. The other RCT reported that the majority of dieticians indicate that the implementation intervention was helpful or very helpful [35]. In one NRSI it was narratively reported that nurses were highly satisfied with the intervention [40]. Knoerl 2021 reported acceptability and feasibility scores only for the intervention group [41]. The results of Phillips 2017 suggested lower self-perceived knowledge directly after the intervention (MD 1.9, 95% CI: 0.5 to 3.4, p = 0.012; eTable 7) and an effect in favour of the intervention at ten weeks after (MD -1.4, 95% CI: -1.9 to -1.0, p < 0.001; eTable 7) [39]. Overall, the interventions may have little to no effect on attitudes, but the evidence is very uncertain due to serious (for RCTs) and very serious (for NRSIs) limitations in the study design, serious indirectness and very serious imprecision of results.

Knowledge

One RCT and one NRSI reported knowledge combined with attitudes scores [38, 42]. The results of Phillips 2017 for perceived knowledge and assessment tool suggested an effect in favour of the intervention measured directly after (MD -1.3, 95% CI: -2.1 to 0.6, p < 0.001 and MD -3.6, 95% CI: -0.5 to 2.2, p < 0.001; eTable 8) and at ten weeks after the intervention (MD -1.7, 95% CI: -2.2 to 1.1, p < 0.001 and MD -3.6, 95% CI: -0.5 to 2.2, p < 0.001; eTable 8), whereas little to no difference has been suggested between these time points (MD -0.3, 95% CI: -1.1 to 0.4 and MD 0.00, 95% CI: -0.7 to 0.7; eTable 8) [39]. Overall, the interventions may have little to no effect on knowledge, but the evidence is very uncertain evidence due to serious (for RCTs) and extremely serious (for NRSIs) limitations in the study design, serious indirectness and very serious imprecision.

Certainty in the evidence

Table 3 provides the GRADE Evidence Profile including the detailed judgement of the certainty and the narrative summary of findings. Overall, the certainty in the evidence was judged to be low for overall survival, quality of life (evidence from RCTs), screening, referrals, prescribing behaviour (evidence from RCTs), and very low for all other outcomes (Table 3). The most frequent reasons for downgrading of the certainty were limitations in the study design, indirectness and imprecision of the results (Table 3).

Table 3 GRADE Evidence Profile Comparison: Multi-component guideline implementation intervention vs no intervention or usual care

Discussion

A total of nine studies, five cluster RCTs and four controlled NRSIs with before-and after study design, were included in the synthesis [34,35,36,37,38,39,40,41,42]. All studies assessed multi-component guideline implementation interventions compared to no intervention in 3577 cancer patients and more than 450 oncologists, nurses and medical staff. Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain. Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

The present review confirms the findings from previous reviews in other clinical settings that educational strategies are the most frequently used strategies for guideline implementation and the most commonly used component in multi-component interventions [22,23,24,25,26, 57, 58]. Compared to the the review of Tomasone et al. [26], this review focuses on more recent literature. While Tomasone 2020 included 33 studies published between 1998 and 2018, we focused on more recent evidence up to December 2022. In contrast to the present review, Tomasone 2020 primarily focused on guideline adherence of healthcare professionals and secondarily on patient-relevant outcomes (survival, quality of life, test completion, pain) and concluded that the most used strategies were educational strategies and feedback on guideline compliance. In addition, the authors used a different taxonomy for coding the interventions, the Mazza taxonomy. This taxonomy builds upon the EPOC taxonomy but has implemented and adapted further domains [59].

A review in the dental care setting [57] showed that multi-component interventions showed slightly higher improvements in guideline adherence outcomes when compared to single interventions. In contrast to the present review, these reviews [57, 58] focused on other clinical settings and included studies conducted in other geographical locations. Moreover, these focused primarily on guideline adherence outcomes. Further, these reviews included a higher number of studies due to different inclusion criteria compared to the current review, such as wider time frames for publication of studies, the inclusion of further study designs (e.g. uncontrolled, retrospective), different classification of interventions, and different outcomes.

Some limitations of the included body of evidence in this review need to be mentioned. For instance, although authors of included studies that did not clearly describe the effect estimates were contacted, no response was obtained, affecting he completeness of the results. Only studies conducted in high-income countries, USA, Australia and France, were identified. Therefore, results may not apply to other countries, where different health systems, local values, and preferences exist. Also, the results may not be generalised to all cancer types or oncological settings. Due to the substantial clinical heterogeneity in participant characteristics, interventions, and outcomes, the pooling of results in meta-analyses was not feasible. This affected the ability of the synthesis to determine the quantitative effect of the interventions.

Potential weaknesses in the review process were that we did not search clinical trial registries due to time constraints, however, this mainly impacts the completeness of the list of ongoing studies and less the results of this review. The time restriction (studies published after 2011) may be interpreted as weakness, as otherwise fitting studies may have been excluded. However, the time frame was chosen to reflect more recent guideline implementation strategies. In addition, the categorisation of interventions conforming to the revised EPOC taxonomy [56] was done by one reviewer (AB) and did not follow a standardised algorithm. This subjective assessment could have introduced bias, as other reviewers could have differently classified the interventions into the predefined categories. The poor reporting of intervention details of some studies amplified the difficulty to classify strategies according to the taxonomy.

One of the strengths of the current review is its comprehensive electronic literature search in five databases, and additionall screening of references of relevant studies and relevant systematic reviews. The search in each database was optimised with the assistance of an experienced information specialist. Six ongoing trials were also included in the review to reflect the latest state of research in this area. Further, this review was conducted according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions [28], of the PRISMA statement [29], in concordance with the EPOC taxonomy [56], and was previously registered in PROSPERO (CRD42021268593).

The effect of CPGs depends on how they are implemented and embedded in clinical practice [13, 16]. The implementation strategies suggested by the German Association of the Scientific Medical Societies (AWMF) coincide with the strategies identified by this review, namely interactive training, discussions, feedback, and local opinion leaders [16]. Moreover, in Germany, guideline-derived Quality Indicators (QIs) are used as key figures during cancer type-specific certification processes in order to determine whether a given center actually provides guideline-based treatment [60]. Here plays the interaction between guideline groups, QIs, certified centers and clinical cancer registries an important role, this being part of the German National Cancer Plan [61, 62]. Additional digital strategies of implementation found in this review, such as online education modules or digital monitoring of patient-reported outcomes, seem to be feasible in the current oncological setting [39, 41]. For instance, online-spaced learning involves the sending of short clinical case-based scenarios that take less than five minutes to consider, to participants’ e-mail or mobile device [39].

Although the evidence of this present review was rated to be low or very low, it does not necessarily mean that these multi-component strategies are not effective in oncology. According to the recommendations of the Institute of Medicine (IOM) and multiple behavioural change frameworks (e.g. COM-B-Behaviour Change Framework [63]), the effect may be amplified when combining many strategies that target the same or different patterns of behaviour change of health professionals and such interventions should be preferred [2]. The current preference for multi-component, professional-targeted interventions in oncology is in line with the implementation of CPGs in other settings [23, 57]. Also, the IOM recommends that “effective multi-component implementation strategies targeting both individuals and healthcare systems should be employed by implementers to promote adherence to trustworthy CPGs” [2]. However, the implementation of multi-component interventions can be demanding as two or more single strategies are involved. Especially, professional-targeted interventions may be hard to implement as behaviour patterns are always difficult to change, regardless of the setting. Moreover, strategies need to be in line with the high volume of recommendations and their frequent updates. This may require resources like time, money, and trained staff. As stated by the ESMO, without adoption in clinical routine practice, “even CPGs of the highest quality may be useless” [8]. In order to be successful, “CPGs have to be developed, disseminated to the right target audience, and finally be implemented” [8]. Facilitators of implementation of CPGs in oncology, found in a recent review, include the accessibility and ease of use of guidelines, dissemination of CPGs, adequate access to treatment facilities and resources, awareness of CPGs, belief in their relevance, and support in decision-making [64]. Furthermore, provider-related barriers such as behavioural patterns of health professionals, values, attitudes, and prior knowledge that affect the adaptability and adherence to changes should be addressed prior to the development of implementation strategies. The focus on local organisational structures, multidisciplinarity of the setting, availability of resources and support is essential when developing guideline implementation strategies. The development of complex and clearly reported interventions based on evidence-based theoretical frameworks may offer a greater potential for changing the clinical practice and a better understanding of barriers and facilitators of guideline implementation [65, 66].

We developed a list of quality parameters for future guideline implementation research that can be found in Fig. 4 (Key Messages Box). High-quality cluster randomized controlled trials and prospectively registered observational studies, designed to primarily assess patient-relevant outcomes emerging from changes in the behaviour of healthcare professionals, are needed. Future studies could consider the analysis of participants in subgroups, as the impact on the various clinical specialities involved in the oncological setting could differ (e.g. doctors vs nurses). In addition, a clear definition of the interventions is essential. The consistency in reporting of the implementation strategies according to a classification framework or taxonomy should be improved in future studies.

Fig. 4
figure 4

Key Messages Box for future guideline implementation research

Conclusions

The results should be interpreted with caution due to the low certainty of the evidence for overall survival, quality of life (in RCTs), screening, referrals, prescribing behaviour (in RCTs), and very low certainty of the evidence for all other outcomes. Team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched strategies in the last years in oncology. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Availability of data and materials

Available at request of the corresponding author.

References

  1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ (Clinical research ed). 1996;312(7023):71–2.

    Article  CAS  PubMed  Google Scholar 

  2. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, editors. Washington (DC): National Academies Press (US); 2011. PMID: 24983061.

  3. Storm-Versloot MN, Knops AM, Ubbink DT, Goossens A, Legemate DA, Vermeulen H. Long-term adherence to a local guideline on postoperative body temperature measurement: mixed methods analysis. J eval Clin Pract. 2012;18(4):841–7.

    Article  PubMed  Google Scholar 

  4. Wiering B, Lyratzopoulos G, Hamilton W, Campbell J, Abel G. Concordance with urgent referral guidelines in patients presenting with any of six “alarm” features of possible cancer: a retrospective cohort study using linked primary care records. BMJ Qual Saf. 2022;31(8):579–89.

    Article  PubMed  Google Scholar 

  5. Bhattacharya D, Easthall C, Willoughby KA, Small M, Watson S. Capecitabine non-adherence: exploration of magnitude, nature and contributing factors. J Oncol Pharm Pract. 2012;18(3):333–42.

    Article  PubMed  Google Scholar 

  6. Ricci-Cabello I, Vásquez-Mejía A, Canelo-Aybar C, Niño de Guzman E, Pérez-Bracchiglione J, Rabassa M, et al. Adherence to breast cancer guidelines is associated with better survival outcomes: a systematic review and meta-analysis of observational studies in EU countries. BMC Health Serv Res. 2020;20(1):920.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Kredo T, Bernhardsson S, Machingaidze S, Young T, Louw Q, Ochodo E, et al. Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care. 2016;28(1):122–8.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Rauh S, Arnold D, Braga S, Curca R, Eckert R, Fröbe A, et al. Challenge of implementing clinical practice guidelines. Getting ESMO’s guidelines even closer to the bedside: introducing the ESMO Practising Oncologists’ checklists and knowledge and practice questions. ESMO Open. 2018;3(5):e000385.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Gundersen L. The effect of clinical practice guidelines on variations in care. Annals Int Med. 2000;133(4):317–8.

    Article  CAS  Google Scholar 

  10. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–20.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Pentheroudakis G, Stahel R, Hansen H, Pavlidis N. Heterogeneity in cancer guidelines: should we eradicate or tolerate? Ann Oncol. 2008;19(12):2067–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39(8 Suppl 2):Ii46-54.

    CAS  PubMed  Google Scholar 

  13. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30.

    Article  PubMed  Google Scholar 

  14. Makarov DV, Sedlander E, Braithwaite RS, Sherman SE, Zeliadt S, Gross CP, et al. A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer. Implement Sci. 2016;11(1):118.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Fishman SM, Young HM, Lucas Arwood E, Chou R, Herr K, Murinson BB, et al. Core competencies for pain management: results of an interprofessional consensus summit. Pain Med. 2013;14(7):971–81.

    Article  PubMed  Google Scholar 

  16. German Association of the Scientific Medical Societies (AWMF)-Standing Guidelines Commission. AWMF Guidance Manual and Rules for Guideline Development, 1st Edition. 2012. English version. Available at: https://www.verwaltung.awmf.org/en/clinical-practice-guidelines/awmf-guidance.html. Accessed 1 Mar 2023.

  17. Giguere A, Legare F, Grimshaw J, Turcotte S, Fiander M, Grudniewicz A, et al. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;10(10):CD004398.

    PubMed  Google Scholar 

  18. Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2011. https://doi.org/10.1002/14651858.CD000125.pub4(8):CD000125.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Pantoja T, Grimshaw JM, Colomer N, Castanon C, Leniz MJ. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev. 2019;12(12):CD001174.

    PubMed  Google Scholar 

  20. Arditi C, Rege-Walther M, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017;7(7):CD001175.

    PubMed  Google Scholar 

  21. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003. https://doi.org/10.1002/14651858.CD000259(3):CD000259.

    Article  PubMed  Google Scholar 

  22. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii iv-1 72.

    Article  PubMed  Google Scholar 

  23. Ebben RHA, Siqeca F, Madsen UR, Vloet LCM, van Achterberg T. Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review. BMJ Open. 2018;8(11):e017572.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Brusamento S, Legido-Quigley H, Panteli D, Turk E, Knai C, Saliba V, et al. Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: a systematic review. Health Policy. 2012;107(2–3):168–83.

    Article  PubMed  Google Scholar 

  25. Kovacs E, Strobl R, Phillips A, Stephan AJ, Müller M, Gensichen J, et al. Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med. 2018;33(7):1142–54.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Tomasone JR, Kauffeldt KD, Chaudhary R, Brouwers MC. Effectiveness of guideline dissemination and implementation strategies on health care professionals’ behaviour and patient outcomes in the cancer care context: a systematic review. Implement Sci. 2020;15(1):41.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hakkennes S, Dodd K. Guideline implementation in allied health professions: a systematic review of the literature. Qual Saf Health Care. 2008;17(4):296–300.

    Article  CAS  PubMed  Google Scholar 

  28. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook. Accessed 1 Mar 2023.

  29. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Sterne JAC, Hernán MA, McAleenan A, Reeves BC, Higgins JPT. Chapter 25: Assessing risk of bias in a non-randomized study. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from http://www.training.cochrane.org/handbook. Accessed 1 Mar 2023.

  31. Higgins JPT, Savović J, Page MJ, Elbers RG, Sterne JAC. Chapter 8: Assessing risk of bias in a randomized trial. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook. Accessed 1 Mar 2023.

  32. Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, Guyatt GH. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editors. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane; 2022. Available from www.training.cochrane.org/handbook. Accessed 1 Mar 2023.

  33. Santesso N, Glenton C, Dahm P, Garner P, Akl EA, Alper B, et al. GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. J Clin Epidemiol. 2020;119:126–35.

    Article  PubMed  Google Scholar 

  34. Lovell MR, Phillips JL, Luckett T, Lam L, Boyle FM, Davidson PM, et al. Effect of Cancer Pain Guideline Implementation on Pain Outcomes Among Adult Outpatients With Cancer-Related Pain: a Stepped Wedge Cluster Randomized Trial. JAMA Netw Open. 2022;5(2):e220060.

    Article  PubMed  PubMed Central  Google Scholar 

  35. McCarter K, Baker AL, Britton B, Beck AK, Carter G, Bauer J, et al. Effectiveness of clinical practice change strategies in improving dietitian care for head and neck cancer patients according to evidence-based clinical guidelines: a stepped-wedge, randomized controlled trial. Transl Behav Med. 2018;8(2):166–74.

    Article  PubMed  Google Scholar 

  36. Mohile SG, Mohamed MR, Xu H, Culakova E, Loh KP, Magnuson A, et al. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet. 2021;398(10314):1894–904.

  37. Gilbert T, Bernard L, Alexandre M, Bin-Dorel S, Villeneuve L, Decullier E, et al. Impact of a Geriatric Intervention to Improve Screening and Management of Undernutrition in Older Patients Undergoing Surgery for Colorectal Cancer: Results of the ANC Stepped-Wedge Trial. Nutrients. 2021;13(7):2347. https://doi.org/10.3390/nu13072347.

  38. Brown B, Young J, Smith DP, Kneebone AB, Brooks AJ, Egger S, et al. A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial. Implement Sci. 2018;13(1):43.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Phillips JL, Heneka N, Hickman L, Lam L, Shaw T. Can A Complex Online Intervention Improve Cancer Nurses’ Pain Screening and Assessment Practices? Results from a Multicenter, Pre-post Test Pilot Study. Pain Manag Nurs. 2017;18(2):75–89.

    Article  PubMed  Google Scholar 

  40. Bonkowski SL, De Gagne JC, Cade MB, Bulla SA. Evaluation of a Pain Management Education Program and Operational Guideline on Nursing Practice, Attitudes, and Pain Management. J Contin Educ Nurs. 2018;49(4):178–85.

    Article  PubMed  Google Scholar 

  41. Knoerl R, Mazzola E, Hong F, Salehi E, McCleary N, Ligibel J, et al. Exploring the impact of a decision support algorithm to improve clinicians’ chemotherapy-induced peripheral neuropathy assessment and management practices: a two-phase, longitudinal study. BMC Cancer. 2021;21(1):236.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Cowperthwaite SM, Kozachik SL. Improving the Pain Experience for Hospitalized Patients With Cancer. Oncol Nurs forum. 2019;46(2):198–207.

    PubMed  Google Scholar 

  43. de Groot JJ, Maessen JM, Slangen BF, Winkens B, Dirksen CD, van der Weijden T. A stepped strategy that aims at the nationwide implementation of the Enhanced Recovery After Surgery programme in major gynaecological surgery: study protocol of a cluster randomised controlled trial. Implement Sci. 2015;10:106.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Luckett T, Phillips J, Agar M, Lam L, Davidson PM, McCaffrey N, et al. Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial. BMC Health Serv Res. 2018;18(1):558.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Pereyra L SL, Criniti J et al. Efficacy of a Mobile Clinical Decision Support System (CaPtyVa CCR App) to Improve Performance of Gastroenterology and Coloproctology Specialists in Colorectal Cancer Screening and Surveillance According to Guideline Recommendations: A Randomized Clinical Trial. 2020, https://clinicaltrials.gov/ct2/show/NCT04389502.

  46. Salz T, Ostroff JS, Nightingale CL, Atkinson TM, Davidson EC, Jinna SR, et al. The Head and Neck Survivorship Tool (HN-STAR) Trial (WF-1805CD): A protocol for a cluster-randomized, hybrid effectiveness-implementation, pragmatic trial to improve the follow-up care of head and neck cancer survivors. Contemporary Clin Trials. 2021;107:106448.

    Article  Google Scholar 

  47. te Boveldt N, Engels Y, Besse K, Vissers K, Vernooij-Dassen M. Rationale, design, and implementation protocol of the Dutch clinical practice guideline pain in patients with cancer: a cluster randomised controlled trial with Short Message Service (SMS) and Interactive Voice Response (IVR). Implement Sci. 2011;6:126.

    Article  Google Scholar 

  48. Milton S, McIntosh J, Macrae F, Chondros P, Trevena L, Jenkins M, et al. An RCT of a decision aid to support informed choices about taking aspirin to prevent colorectal cancer and other chronic diseases: a study protocol for the SITA (Should I Take Aspirin?) trial. Trials. 2021;22(1):452. https://doi.org/10.1186/s13063-021-05365-8.

  49. Foley KL, Miller DP Jr, Weaver K, Sutfin EL, Petty WJ, Bellinger C, et al. The OaSiS trial: A hybrid type II, national cluster randomized trial to implement smoking cessation during CT screening for lung cancer. Contemp Clin trials. 2020;91:105963.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Daniel CL, Armstrong GT, Keske RR, Davine JA, McDonald AJ, Sprunck-Harrild KM, et al. Advancing Survivors’ Knowledge (ASK) about skin cancer study: study protocol for a randomized controlled trial. Trials. 2015;16:109.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Caminiti C, Iezzi E, Passalacqua R. Effectiveness of the HuCare Quality Improvement Strategy on health-related quality of life in patients with cancer: study protocol of a stepped-wedge cluster randomised controlled trial (HuCare2 study). BMJ Open. 2017;7(10):e016347.

    PubMed  PubMed Central  Google Scholar 

  52. Lovell M, Davidson P, Luckett T, Stubbs J, Agar M, Boyle F, et al. Implementation Strategies for Cancer Pain Management Guidelines. Abstracts of the 9th World Research Congress of the European Association for Palliative Care (EAPC). 2016; Abstract number P088. Available from https://journals.sagepub.com/doi/pdf/10.1177/0269216316646056. Accessed 1 Mar 2023.

  53. Lovell M, Phillips J, Luckett T, McCaffrey N, Lam L, Boyle F, et al. A cluster randomised controlled trial of guidelines and screening with implementation strategies versus guidelines and screening alone to improve pain in adults with cancer. Abstracts for MASCC/ISOO Annual Meeting 2021. Abstract Nr. CANCE-03. Available from https://link.springer.com/article/10.1007/s00520-021-06285-8. Accessed 1 Mar 2023.

  54. Lovell M, Philips J, Luckett T, Agar M, Lam L, McCaffrey N, et al. Cancer Pain: Bridging the Evidence-practice Gap. Abstracts of the 9th World Research Congress of the European Association for Palliative Care (EAPC). 2016; Abstract number P091. Available from https://journals.sagepub.com/doi/pdf/10.1177/0269216316646056. Accessed 1 Mar 2023.

  55. Julin MJ, Ochoa S, Cooper D, Dabney B. Using the Oncology Care Model to Manage Cancer Pain at an Outpatient Oncology Clinic. Clin J Oncol Nurs. 2022;26(1):E7–13. https://doi.org/10.1188/22.CJON.E7-E13

    Article  PubMed  Google Scholar 

  56. EPOC Taxonomy 2015. Available from https://zenodo.org/record/5105851#.Yue9J2PP1PY. Accessed 20 Jan 2023.

  57. Villarosa AR, Maneze D, Ramjan LM, Srinivas R, Camilleri M, George A. The effectiveness of guideline implementation strategies in the dental setting: a systematic review. Implement Sci. 2019;14(1):106.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Spoon D, Rietbergen T, Huis A, Heinen M, van Dijk M, van Bodegom-Vos L, et al. Implementation strategies used to implement nursing guidelines in daily practice: A systematic review. Int J Nurs Stud. 2020;111:103748.

    Article  PubMed  Google Scholar 

  59. Mazza D, Bairstow P, Buchan H, Chakraborty SP, Van Hecke O, Grech C, et al. Refining a taxonomy for guideline implementation: results of an exercise in abstract classification. Implement Sci. 2013;8:32.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Nothacker M, Bolster M, Steudtner M, Arnold K, Deckert S, Becker M, et al. International experiences in the development and implementation of guideline-based quality indicators: a qualitative study. BMJ Open. 2021;11(1):e039770.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Follmann M, Eigentler T, Adam H, Wenzel G, Langer T, Wesselmann S. Quality assurance in melanoma care: guideline-based quality indicators for melanoma - implementation, evaluation and update process. J Dtsch Dermatol Ges. 2020;18(8):848–57.

    PubMed  Google Scholar 

  62. Bundesgesundheitsministerium. Nationaler Krebsplan – Handlungsfelder, Ziele und Umsetzungsempfehlungen. 2022. Available from https://www.bundesgesundheitsministerium.de/themen/praevention/nationaler-krebsplan/der-nationale-krebsplan-stellt-sich-vor.html. Accessed 20 Jan 2023.

  63. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Bierbaum M, Rapport F, Arnolda G, Nic Giolla Easpaig B, Lamprell K, Hutchinson K, et al. Clinicians’ attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature. Implement Sci. 2020;15(1):39.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Noar SM, Zimmerman RS. Health Behavior Theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Educ Res. 2005;20(3):275–90.

    Article  PubMed  Google Scholar 

  66. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7:38.

    Article  PubMed  PubMed Central  Google Scholar 

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Open Access funding enabled and organized by Projekt DEAL. We acknowledge support for the Article Processing Charge from the DFG (German Research Foundation, 491454339). 

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Methodological expertise, conception and writing of the manuscript: AB. Methodological expertise, advice, conception and review of the manuscript: NK, VP, NS. Methodological expertise, advice, and review of the manuscript: MF, MN. Methodological expertise, risk of bias check: NK, VP, AW. Optimisation of the search strategies: IM. The author(s) read and approved the final manuscript.

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Correspondence to Ana-Mihaela Bora.

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Supplementary Information

Additional file 1.

Search strategies. List of excluded studies at full-text screening stage. Population characteristics. Detailed description of interventions of included studies. Reported outcomes in the included studies. Characteristics of ongoing studies. Characteristics of studies awaiting classification. Risk of bias judgement for randomized controlled trials. Risk of bias judgement for non-randomized controlled studies of interventions. Risk of bias summary plots. Outcome effect tables. PRISMA Checklist.

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Bora, AM., Piechotta, V., Kreuzberger, N. et al. The effectiveness of clinical guideline implementation strategies in oncology—a systematic review. BMC Health Serv Res 23, 347 (2023). https://doi.org/10.1186/s12913-023-09189-x

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Keywords

  • Clinical practice guideline
  • Implementation
  • Oncology
  • Patient-relevant outcomes
  • Healthcare professionals
  • Guideline adherence
  • Behaviour