Table 3 Facilitators and barriers of guideline implementability as perceived by Family Physicians: CONTENT

Specific content to include (N = 17)

Goals and targets (N = 2)

● Provide easily understandable goals and targets that can be applied in practice. {I-1}

Does not include specific targets (N = 1)

● Some guidelines like Diabetes are hard to follow because they include sections at the end with special groups. It’s important that these subgroups [aboriginal] are mentioned because they are higher risk group and you have to keep a closer eye on them for complications but the recommendations become more defuse or nebulous or vague that obviously come out of some evidence base but don’t provide specific targets to follow and are not useful for every day frontline practice situations {I-1}

● Like to see a clear statement of the targets aimed for {FG4-P2}

Whether targets are practical and feasible (N = 1)

● Whether guidelines are practical, feasible are the most important in terms of the numbers that should be targeted (for example in hypertension guidelines) in terms of the first, second, third-line medications {I-4}

Targets that are difficult to achieve (N = 2)

● In hypertension guidelines it’s very hard to achieve the targets that they recommend {I-4}

Targets constantly changing (N = 1)

● Sometimes targets [such as in Cholesterol guidelines] are unattainable because they are always changing and difficult to achieve in the real world {FG3-P2}

Clear statement of screening, diagnosis and treatment (N = 1)

● Like to see a clear statement of the screening and diagnosis or management, and the targets aimed for {FG4-P2}

Which tests to order (N = 1)

● There is a point of frustration for me sometimes, like what tests to order [Right] you know, like for TSH {FG4-P1}

Guidance on atypical situations (N = 1)

● Guidelines should provide guidance on what is atypical - to know the procedure or how to investigate the red flags in a timely manner; to know what to do and is appropriate for things that are not as common like retinal detachment - to know the red flags and what to look for and what procedure to investigate in a timely manner {I-8}

Does not include number needed to treat (N = 1)

● The thing I always look at is, is the sort of how many people needed to treat you know, so if I have to put 1000 of my patients on beta blockers to save one MI you know, that's not going to be implemented or the guideline I am going to get very excited about. So the number needed to treat, are the things I think are not available in guidelines and should be, because that's the evidence. {FG1-P3}

Guidance on uncertainties (N = 1)

● It's good that Hypertension guidelines address uncertainties so you know what to do for high risk, intermediate and low risk patients (e.g., controversies around the secondary markers besides LDL and HDL). {I-6}

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Guidance on exceptions (N = 1)

● Include exceptions and how to deal with them {I-1}

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-

Controversies (N = 1)

● In some cases, you would want more information. They have to show the controversy and they've got to show how they've looked at both sides {I-6}

Ignores controversy (N = 1)

● It isn't helpful if a guideline doesn’t address areas of controversy or ignores it {I-6}

How long things should take (N = 1)

● In some investigations where timeline is an issue, it would be helpful if guidelines included information on how long it should take or don't leave it more than this long or investigate this and then this or do all {I-8}

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When to refer (N = 1)

● It would be good to know when to refer. I sometimes refer and then the specialists comes back to ask why I referred {FG2-P2}

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Information about evidence (N = 16)

Include evidence (N = 5)

● Provide evidence and its quality {I-1}

Including weak evidence (N = 3)

● Grade D evidence should not be considered or included in guidelines {FG1-P3}

Provide the evidence behind recommendations {FG1-P2}

Include information on quality of evidence (N = 6)

● Guidelines should provide the strength and quality of evidence with the statement {FG1-P1}

Recommendations supported by mid-level evidence (N = 1)

● The most difficult is to follow a guideline with mid-level type of evidence where I’m not quite sure which direction to follow – If its B, C or D, it is against consensus which is what makes it much more difficult – I question using that particular guideline and makes it difficult for me to implement that into my practice {FG1-P2}

● If it’s Grade A evidence, then I feel much more comfortable using that {FG1-P2}

Provide flow sheets (N = 1)

● For more complex evidence, provide flow sheets {FG1-P1}

Information about medications (N = 15)

Include medication costs (N = 6)

● Specialists will say that patients with hypertension are not being treated adequately and family physicians are not doing a good job but sometimes it’s difficult to follow guidelines because of cost of medication and so we can’t do exactly what the guidelines say {FG3-P3}

No information on medications (N = 1)

● Many times, I get a report back that is totally useless because it’s not telling me whether or not the drug my patient is taking is effective or not, that is, it’s not clear whether it’s simply not reported in the guideline because the guideline committee decided to leave out this information {I-10}

Include medication choices (N = 5)

● Guidelines should point in the right direction if the first or second-line treatments aren't going to work for whatever reason. I like how the hypertension guideline help you choose the right drug - the ones that integrate into the way do things anyway (which drug to choose first). It lays it out clearly and characterize the type of patient that would do better with this drug vs another - particularly in my practice where I have a multicultural practice because certain populations are different and you want to know that {I-8}

Does not address the pros and cons of medications (N = 1)

● Guidelines don’t strongly address the pros and cons of medications (e.g., bisphosphonates for osteoporosis) {I-6}

Include brand names (N = 1)

● Guidelines could provide the brand names in brackets for the common medications. {FG2-P1}