A mixed methods evaluation of American society of Hematology's (ASH) clinical guidelines

Abstract

Abstract Introduction: Clinical guidelines are evidence-based recommendations for diagnosing and treating a medical condition. Guideline recommendations are actionable statements that when applied in practice will improve patient care. However, the development of guidelines does not automatically equate to practice change. Barriers to practice change are multi-level and underutilization of recommendations can result in patients not receiving evidence-based treatment. Although the American Society of Hematology's (ASH) guidelines have been heavily cited, no one has evaluated their utilization. The goal of this study is to evaluate the utilization of ASH practice guidelines. Methods: We are currently conducting an explanatory sequential mixed methods study. Eligible providers are adult medical professionals practicing in the United States (US). Ongoing recruitment includes: snowball sampling, ASH email to US-based members and/or practice subscribers, survey link in the ASH NewsLink newsletter, and posting on social media. A validated survey (Clinician Guideline Determinants Questionnaire) is administered online. The survey takes <10 minutes to complete and includes: 1) demographics, 2) clinician and guideline specific determinants, 3) enablers/barriers, 4) preferred learning style, and 5) usefulness of implementation tools. The survey has Likert scale response options ranging from ‘Strongly Disagree’ to ‘Strongly Agree’. At the end, participants can agree to an interview. Individual interviews utilize a semi-structured discussion guide focusing on familiarity with guideline recommendations, implementation into clinical practice, awareness/use of ASH dissemination tools, and beliefs related to trustworthiness and utility of guidelines. All interviews are conducted via Zoom and are approximately 30 minutes long. Analysis: Descriptive statistics are used to describe the demographics of participants. To understand enablers and barriers, we stratified participants into users and non-users of guidelines. Survey responses with > 50% missing data are excluded. Interviews are recorded and transcribed verbatim. Three researchers independently identified emerging themes then met to discuss and reach agreement on high-level concepts and preliminary themes. Results: To date, there have been 207 survey responses, 59 were excluded due to > 50% missing data, resulting in 148 evaluable responses. Only 107 participants completed demographic information. Participants are 56% female, 57% White, 84% not Hispanic/Latino, and the mean age is 47 years (range 31-83). The majority (93%) are current ASH members, 92% work in academia, and 91% specialize in hematology (hematology, hematology-oncology, pediatric hematology). Users of guidelines identified the top enablers of guideline utilization: 1) possessing the skills needed to use the guideline, 2) possessing the knowledge to use the guideline, and 3) guidelines being consistent with current evidence. Non-users of guidelines identified the top barriers preventing utilization of ASH guidelines: 1) being an expert and therefore not needing guidelines, 2) perceiving other organizations had superior guidelines on the same condition, and 3) perceiving ASH guidelines as outdated and not reflective of current clinical practice. Preliminary qualitative themes focus on awareness and use of ASH dissemination tools (n=26 interviews). When utilizing the guidelines in practice, providers simply used 'Google’ and found them online. In contrast, although providers were aware of the ASH pocket guides, they did not utilize them in practice. Only a few providers were aware of the ASH guideline mobile application, and it was suggested that its utility would be improved if it could reflect treatment updates in real time. Finally, most providers were unaware of the ASH teaching slide sets and snapshots. Regarding ideal dissemination tools, providers suggested that ASH consider developing an interactive tool that allows for keyword searching and dynamic branching for diagnosis versus treatment. Conclusion: There was positive support for ASH's guideline efforts. Our results revealed individual expertise and guidelines reflective of current clinical practice as overlapping enablers and barriers. This may reflect the vast differences in hematologic disorders and treatment paradigms. Additionally, ASH should consider dissemination tools that allow for continuous updates reflective of evolving treatment landscapes.