Table 3 Thematic conceptual matrix of integrated qualitative and quantitative findings

Subtheme 1.1: Applicability of recommendations to patient population

CPGs do not or cannot cater for all patient complexities (n = 25) [1 A]

Agreement

Clinicians agreed that CPGs do not: take patient clinical presentations or complications (74.5%), comorbidities (81.4%) or patient age into account (65.2%) [1B].

CPGs provide a reassuring framework to confirm treatment plans (n = 24) during complex/unfamiliar/rare cases, or new treatments (n = 13) [1 A]

Agreement

CPGs support treatment decision making in complex cases (83.7% agreed) [1B]

CPGS reduce clinical variation and improve patient care (n = 8) [1 A]

Agreement

Clinicians agreed that CPGs help to standardise care (95.4%), and improve patient outcomes (97.7%) [1B]

CPGs are helpful, educational tools, particularly for common cancer cases (n = 9) [1 A]

Agreement

Clinicians agreed that CPGs are convenient sources of advice (97.8%), are practical to use (90.9%), and are good educational tools (100%) [1B]

Subtheme 1.2: Degree of evidence and level of agreement with evidence underpinning CPGs

A lack of agreement with the interpretation of underpinning evidence (particularly when controversial or conflicting) makes it difficult to decide which CPG to follow (n = 6) [2 A]

Discordant

Clinicians disagreed that; their lack of confidence in the interpretation of evidence underpinning CPGs (76.8%), and having multiple CPGs that provide contradictory advice were barriers to adherence (74.4%) [2B]

Subtheme 1.3: Format- ease of use, references to evidence, and inclusion of patient resources

Provision of a summary of evidence with reference to the clinical trials underpinning recommendations was a perceived facilitator (n = 15) [3 A]

Agreement

Clear reference to evidence justifying recommendations facilitates adherence (97.6% agreed) [3B]

Statements that highlight the level of evidence (or consensus) that recommendations are based on (n = 5) were considered a facilitator [3 A]

Agreement

Clear labelling of consensus-based recommendations facilitates adherence (97.7% agreed) [3B]

It is a perceived barrier to adherence when CPGs are difficult to navigate (n = 3) [3 A]

Complementary

CPGs are cumbersome and inconvenient (77.3% disagreed) [3B]

Subtheme 1.4: How up-to-date CPGs are

CPGs being slow to be updated (n = 23) [4 A] or underpinned by rapidly changing evidence (n = 19) [2 A] were barriers, while regular updates facilitated adherence (n = 16) [4 A]

Agreement Complementary

Regular updates to CPGs facilitate adherence (100% agreed).

CPGs are too out-of-date to be practically useful (68.2% disagreed) [4B]

Subtheme 1.5: Prescriptiveness of CPG recommendations

CPG content that was too broad for complex cases (n = 11) or too rigid, not taking account of emerging evidence (n = 5) were perceived barriers [5 A]

Complementary

CPGs are too rigid to apply to individual patients (63.6% disagreed) [5B]

Subtheme 2.1: Clinician personality, and the impact of CPGs on autonomy

Clinician equipoise and hubris was seen to act as a barrier to adherence (n = 11), as was concern that CPGs can lead to cookbook, or “cookie cutter” medicine, reducing clinician autonomy (n = 2) [6 A]

Discordant

Clinicians disagreed that they; prefer to use their own judgement to inform treatment decisions (74.4%), prefer to continue their routines rather than to change based on CPGs (100%), that CPGs interfere with professional autonomy (93.1%), and that CPGs are too prescriptive (77.3%) [6B]

Subtheme 2.2: Generational and disciplinary differences in perceptions towards CPGs

Some clinicians were perceived as biased by a preference for their discipline, or financially incentivised to complete treatment with the patient rather than engage in multidisciplinary care (n = 7) [7 A]

Discordant

There was no significant difference in CPG attitude scores across subgroups: age groups (p = 0.143), disciplinary groups (p = 0.052), position, (p = 0.307), year clinician graduated from medicine (p = 0.056), or year clinician graduated from oncology specialty (p = 0.592) [7B]

Senior clinicians were perceived as less inclined to refer to CPGs, compared to more junior clinicians (n = 7) [7 A]

Agreement

The age of clinicians (p = 0.007) and the number of MDTs clinicians attend (p = 0.03) were associated with frequency of referral to CPGs [7B]

Subtheme 2.3: Litigation concerns

Concerns around litigation may be a reason CPGs are not developed, particularly regarding treatment doses (n = 1) [8 A]

Discordant

Publishing CPGs increases the risk of malpractice liability (90.9% disagreed) [8B]

Possible litigation and the need to justify and communicate treatment decisions clearly was a facilitator (n = 18) [8 A]

Agreement

Adhering to CPG recommendations covers clinicians medicolegally (79.1% agreed) [8B]

Subtheme 2.4: Patient age, comorbidities, preferences and logistics

Patient preference was a perceived barrier to adherence, including concern about side effects, toxicity, and treatment tolerability (n = 21) [9 A]

Agreement

Patients refusing CPG adherent care is a barrier to adherence (86% agreed) [9B]

Geographic challenges and logistics for rural and remote patients travelling long distances to access treatments was a perceived barrier (n = 10) [9 A]

Discordant

Patient logistics such as living remotely and requiring travel to access treatments acted as a barrier (55.8% disagreed) [9B]

Clinician concern about toxicity or potential side effects of a treatment and treatment tolerability was perceived as a barrier to adherence (n = 7) [9 A]

Discordant

Concern about CPG recommended treatment side effects was a barrier to adherence (74.5% disagreed) [9B]

Subtheme 3.1: Access to, awareness of and availability of CPGs

Some clinicians felt others’ limited awareness of CPGs or where to access them acted as a barrier to adherence (n = 5) [10 A]

Complementary

Clinicians were familiar with the CPGs in their field (97.7%) and felt they were readily available (93.2%). Clinicians disagreed that CPGs were not accessible (76.8%) and that their own lack of awareness of CPG recommendations was a barrier (90.7%)[10B]

Hard to access CPGs that require a login were barriers to adherence (n = 10), and that easy access to CPGs was a facilitator (n = 19) [10 A]

Agreement

Easy access to CPGs with no login requirements facilitates adherence (93% agreed) [10B]

Subtheme 4.1: Access to treatments recommended by CPGs, resource availability and clinician time

Limited availability of drugs (with PBS funding) was a barrier (n = 19) [11 A]

Neutral

A lack of access to CPG recommended drugs was a barrier (50% agreed) [11B]

Organisational support and resources were a facilitator (n = 6) [11 A]

Complementary

There is sufficient support and resources to implement CPGs (50% agreed) [11B]

High clinician workload, limited staffing, and a lack of clinician time can prevent clinicians from looking up CPG recommendations (n = 7) [11 A]

Agreement

Clinicians agreed they do not have time to stay informed about available CPGs (70.5%) and there are so many CPGs available that it is nearly impossible to keep up (63.6%) [11B]

Subtheme 4.2: A culture of peer review or multidisciplinary review of treatment plans

Peer expectation to adhere, fear of looking negligent if non-adherent and knowing that peers adhere were seen as facilitators (n = 10) [12 A]

Agreement

If colleagues’ practice is adherent that encourages clinicians to adhere (76.7% agreed). Clinicians disagreed that they are not expected to use CPGs in their practice setting (97.8%) [12B]

Multidisciplinary engagement or MDT attendance (n = 24) and peer review of treatment decisions (n = 15) [12 A] were seen as facilitators of adherence

Agreement

Clinicians agreed that multidisciplinary review of treatment decisions (93.1%) and peer review of treatment decisions (95.3%) facilitate adherence [12B]. The number of MDTs that clinicians attend was associated with frequency of referring to CPGs (routinely/occasionally vs. rarely/never): 57.9% of clinicians (n = 11) who attend one or two MDTs reported that they routinely or occasionally refer to CPGs, compared to 90.9% of clinicians (n = 20) who attend 3 or more MDTs, p = 0.03 [12B]

Subtheme 4.3: Referral pathways

Patient referral pathways that circumvent multidisciplinary review act as barriers (n = 8) as does lack of awareness by GPs (and patients) of the importance of multidisciplinary review (n = 6) [13 A]

Silence (Expected)

Subtheme 5.1: Development, adaptations, and review of CPGs, by an expert development committee

Clinicians felt biased CPGs were a barrier to adherence (n = 11) [14 A]

Agreement

Clinicians agreed that adherence was facilitated when CPGs were based on unbiased synthesis of robust scientific evidence (81.8%) or unbiased syntheses of expert opinion (75.1%) [14B]

CPG development by trusted and respected experts transparently and methodically, with multidisciplinary and patient representation on the development committee was a perceived facilitated (n = 16) [14 A]

Complementary

Clinicians agreed that development of CPGs by a trusted expert committee facilitates adherence (90.7%), however 86% disagreed that their lack of confidence in CPG developers was a barrier to adherence [14B]

Subtheme 5.2: CPG dissemination and implementation strategies

Clinical audits of adherence rates were seen as facilitators by some (n = 9) while other clinicians felt audits do not reflect warranted variation, highlighting that low adherence may reflect a poor-quality CPG (n = 11) [15 A].

Agreement

Clinical practice audits of CPG adherence facilitate adherence (88.1% agreed) [15B]

Subtheme 5.3: Suggested development and implementation improvements

Clinicians suggested adapting international CPGs to local needs (n = 9) and developing a comprehensive, continuously updated, dynamic, wiki-like CPGs database, managed by a well-resourced national group (n = 6) [16 A]

Agreement

Clinicians suggested more: frequent updates (n = 4), accessibility (n = 4), development of living (wiki) CPGs (n = 4), reference to CPGs in MDTs (n = 3), development of Australian CPGs or adaptations that reflect PBS drug availability (n = 2) with a template-summary of evidence levels underpinning recommendations (n = 2), and development by a national group (n = 1) [16B].