Definitions used for this review
- Barriers are defined as any factor that obstructs or limits or restricts the capacity for medical professionals to implement CIGs in their routine clinical practice.
- Facilitators are defined as factors that enable the implementation of CIGs’.
- Clinical Imaging Guidelines or clinical imaging referral guidelines, or clinical diagnostic imaging guidelines are systematically developed evidence-based statements to assist referrers, radiological imaging practitioners and patients to make decisions about the appropriate care for specific conditions (57).
- Medical profession
These are defined as any medical professionals of any type based in health care settings (e.g., hospitals, ambulatory clinics, community-based physician offices) who prescribe or refer patients for imaging procedures including specialists, general medical practitioners, doctors in training, and allied health professionals who are entitled to request radiological examinations.
An expert will be a person who knows a lot about imaging guidelines based on the expert’s publication in that area, work experience or as recommended by the relevant professional bodies.
Study design
This will be a mixed studies review including both qualitative and quantitative studies. Randomized and non-randomized controlled trials, quasi-experimental/ before and after studies, prospective and retrospective cohort studies, descriptive study designs including case series, case reports, descriptive cross sectional studies, focus groups interviews and program evaluations that describe methods to implement guidelines or promote compliance Systematic reviews will not eligible but will be used to identify additional eligible primary studies.
This protocol has been written according to the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to enhance methodological transparency and improve the reproducibility of the results and evidence synthesis (58)
The PRISMA-P checklist is given in the Additional file 1.
Eligibility criteria
Studies will be selected according to the following inclusion
- Primary Research
- All studies that provide data for either of these two outcomes (barriers and or felicitators to CIG implementation).
- All study designs /All evidence levels from RCT to expert opinion
- Only studies in English
- There will be no limit imposed by year of publication
- When more than one publication described a single study and each presents the same data, we shall include only the most recent publication.
However, when more than one publication describes a single study but each presents new and complementary data, all shall be included
Participants/population
Populations referred to are various medical professionals of any type based in health care settings (e.g, hospitals, ambulatory clinics, community-based physician offices) who prescribe or refer patients for imaging procedures (specialists, general medical practitioners, doctors in training, allied health professionals who are entitled to request radiological examinations). The review will consider any age and any gender
Intervention
Diagnostic Imaging Referral Guidelines (also called Imaging referral guidelines, clinical imaging guidelines, decision support tools), hear referred to as Clinical Imaging guidelines (CIGs) are evidenced based tools to support referrers, radiological imaging practitioners and patients to make decisions in the selection of appropriate diagnostic imaging procedures for a specific condition. Imaging referral guidelines provide physicians with information regarding which procedure is most likely to yield the most informative results, and whether another modality is equally or more effective. Guidelines for clinical imaging are also referred to as “appropriateness criteria,” “referral guidelines,” and “justification criteria” (29-32). Their use improves appropriateness and justification of radiological procedures thereby reducing unnecessary radiation exposures and efficient as well as effective utilization of resources, with ultimate enhancement of quality of care. Only imaging referral guidelines that are endorsed by a national governmental or professional association, provider organization related to imaging will be included in this review. The definition of CIG for purposes of this review will encompass all formats of imaging referral guidelines (e.g. tabulated vs flow charts) and media (e.g. hard copy, electronic copy, interactive web-based, smart phone-based, clinical decision support systems etc.) will be included.
Comparator (s)/control
None
Outcome
Outcomes reported in the eligible studies and are relevant to the study type: perceived or experienced barriers or facilitators to CIGs implementation will be considered as primary outcomes.
Additional outcomes of the review will include any recommended interventions or strategies to promote guideline use.
Setting
The intervention should be CIGs used in hospitals, healthcare organizations, health care ministries, primary health care, outpatient clinics, or general practitioner's offices).
Exclusion criteria
- Studies that were based on infection control, quality improvement, patient safety, client-centeredness, or organizational “best practices” but did not explicitly name and reference an imaging guideline
- Commentaries, articles with missing abstracts, but letters to the editor, considered as “exert opinion”, shall be include.
- Studies with disease-specific information on barriers and/or strategies, which do not allow for generalizations
- Guidelines focused on cancer screening which is are not generalizable and have nothing to do with CIG of any type.
The Search Strategy
Information sources
Electronic searches
Electronic databases will be searched to identify all the relevant studies. We shall search the following electronic databases:
- PUPMED/MEDLINE
- EMBASE
- Web of Science
Other methods to be used for identifying relevant research
- Google Scholar - this will identify information that may be missed out in the journal databases.
- The grey literature – this consist of unpublished reports, dissertations and theses, non-referenced publications
- Reference list of all included and excluded studies
Search engines and websites of conferences proceedings, or meeting. proceedings and papers, ongoing research and expertise: Contacting experts in this field e.g. from professional bodies like American College of Radiologists, Royal College of Radiology, European Society of Radiology, World Health Organization, International Atomic Energy Agency.
Search Strategy
The search algorithm will be developed with advice of an experienced librarian. This will focus on the keywords and their synonyms.
The search terms will be based on the title and research questions and these will be categorized under Population, intervention, comparisons, (PICO) outcomes) framework as in Table 1
Table 1: Terms to be used in literature search
Population
|
Medical professionals
Healthcare providers OR healthcare workers OR physicians OR clinicians OR general practitioners
|
Intervention and synonyms,
|
Clinical imaging guidelines
Clinical imaging referral guidelines , diagnostic imaging referral guidelines, decision support tools, Appropriateness criteria, ” Decision support tools, Computerized decision support tools, diagnostic imaging pathways, making the best use of a radiology department, “iReffer’. iGUIDE,
|
Comparator
|
None
|
Outcome
|
Barriers, compliance, adherence, usage, facilitators, strategies, opportunities
|
The search terms will include the following:
- Clinical imaging - Clinical imag* OR diagnostic imag* OR referral* AND (guidelines OR decision support tools) OR radiology OR radiography OR Medical imag* OR “unnecessary imaging” OR “unwarranted imaging” OR overutilization OR overus* Clinical imaging referral guidelines , diagnostic imaging referral guidelines, decision support tools, Appropriateness criteria, ” Decision support tools, Computerized decision support tools, diagnostic imaging pathways, making the best use of a radiology department, “iReffer’. iGUIDE,
- Medical professionals - Healthcare providers OR healthcare workers OR physicians OR clinicians OR general practitioners, referrers, referring clinician, prescribers,
- Barriers OR compliance OR adherence OR usage OR facilitators OR strategies OR opportunities
Data management
An experienced librarian will perform an initial search of PubMed (Medline) and EMBASE using keywords and Medical Subject Headings (MeSH) guided by the search strategy list above. Inclusion/exclusion of studies retrieved from the search will be based on the title and abstracts only during the first stage of screening. A second search using all identified keywords and index terms will then be undertaken across all included databases, thirdly, the reference list of all identified reports and articles will be searched for additional studies. All titles and abstracts generated by the searches will be downloaded into EndNote reference manager for screening. Duplicates will be removed. A Microsoft Excel spreadsheet will be used to record the decision making of the screening process. Citations deemed relevant will be selected and the papers retrieved for full-text eligibility screening. Any studies where decision cannot be made whether to include or exclude in the first stage, further reading of the full text will be done before a final decision is made. Studies identified through reference list screening will undergo the same approach.
Selection, appraising and extraction of data from the research papers
Screening process
Initially, two reviewers (KHN and AOS) will independently scrutinize titles and abstracts in English for eligibility. Citations deemed relevant by either reviewer will be selected and the papers retrieved for full-text review. Next, each eligible article will be independently assessed by the two reviewers against the selection criteria. In addition, the references of the relevant articles will be reviewed. Disagreements will be resolved by discussion between the reviewers and consensus. A third reviewer (MGK) will be the tiebreaker if still fails to agree. A list of excluded studies with their reasons for exclusion will be maintained. A standardized template generated from the inclusion and exclusion criteria based on PICO (population, intervention, comparisons, outcomes) framework) will be used to screen for eligibility of a study. All members of the research team will review eligibility criteria and provide feedback, which will be used to refine the eligibility criteria. The research team will comprise of radiologists, evidence-based scientists, and systematic review methodologists. The template will have a list of questions that help to identify those studies that meet the inclusion criteria. If all questions are answered in affirmative, that study will be included, but if the questions are answered in the negative way, such studies will be excluded.
Risk of bias (quality) assessment
Quality assessment of included studies will be based on an existing framework and its set of validated tools (59-61).This framework is selected because its authors provide reviewers with a manual for definitions and detailed instructions, which eases quality scoring of quantitative, qualitative and mixed methods studies. These tools allow for an overall assessment of key biases of the included studies, and the final quality ratings will be then be utilized to assess the reliability of the identified factors.
Two reviewers (KHN and AOS) will independently assess the quality of each study. Discrepancies between the two reviewers will be resolved by consensus through discussion with a third reviewer (KGM) as the tiebreaker.
A list of excluded studies with their reasons for exclusion will be maintained.
Data extraction
A data extraction sheet based on a taxonomy of barriers and facilitators to implementing clinical practice guidelines in actual practice (62, 63) will be used. This particular taxonomy was previously used in two previous studies and found it compared well to other taxonomies. One study assessed health professional’s perceptions in regard to barriers and facilitators to implementing shared decision-making in clinical practice (64) and the second one studied the factors affecting general practitioners' decisions about plain radiography for back pain by Espeland and colleagues (63)
Two reviewers will independently extract all relevant data using a pre-developed standardized form. Differences will be resolved by consensus through discussion with a third reviewer (KGM) as an arbitrator if no agreed conclusion is reached.
The following categories of data will be extracted (1) identification of the study (article title; journal title; impact factor of the journal; authors; country of the study; language; publication year; host institution of the study (hospital; university; research Centre; single institution; multicentre study); (2) methodological characteristics (study design; study objective or research question or hypothesis; sample characteristics, eg, sample size, sex; age, race; groups and controls; types of CIGs implemented (description of the guideline, intended users , development team ),implementation strategy, inter-rater reliability ; statistical data analyses, adjustments (3) main findings (barriers and facilitators in implementing CIGs), use of a conceptual framework (e.g. the physician’s area of practice such as family medicine, emergency medicine, etc.) including themes and subthemes, rating scheme for the strength of the evidence and recommendation, method of validation and (4) conclusions
For qualitative studies, interview and focus-group quotes will be double-extracted in separate documents. Two reviewers will meet and review all identified factors, discuss until consensus is reached. A list of excluded studies with their reasons for exclusion will be maintained.
Data synthesis
All results will be subjected to a double data entry. If two or more of the included quantitative studies are sufficiently homogeneous and are of adequate quality, a meta-analysis will be performed and effect sizes calculated using appropriate software.
Odds ratios for categorical data and weighted mean differences for continuous data and their 95% confidence intervals will be calculated for effected sizes using analysis. / For dichotomous data, the effect sizes will be expressed in terms of relative risks and 95% CI. Heterogeneity will be assessed statistically using the Chi-square statistics and if appropriate, explored using subgroup analyses based on different quantitative study design included in the reviews.
For the outcomes where statistical pooling is not possible a descriptive synthesis of the quantitative the findings will be presented in narrative form such as summary tables and figures.
For qualitative studies two reviewers will independently read each publication and identified the unit of text (a sentence or paragraph representing one idea) relevant to each of the main outcomes of interest (barriers or facilitators to the implementation of CIGs in clinical practice). Each unit of text will then be coded according to the relevant and pre-established code list and entered into an Excel spreadsheet using a framework synthesis approach, NVivo 11 software will be used for data management.
Units of text which could not be coded will be discussed by the two assessors and new codes will be created as necessary. Discrepancies between the coders will be resolved through discussions and concession. Themes will be ordered according to the number of studies in which they are identified. Where textual pooling is not possible the findings will be presented in narrative form. To analyze the included studies, a thematic analysis will be conducted, in line with best practice when aggregating data from different types of research (65, 66).
Specifically, all identified factors will be organized into barriers and facilitators and counted by frequency. The identified factors will then be categorized following thematic analysis (67). Identified factors will only be counted once per study, except when a study identifies factors specific to different subgroups (e.g. according to different organizational cases or by different types of evidence-based practice.
The synthesis of quantitative results will be integrated with the analysis of qualitative papers, using thematic analysis. The guidelines "Consolidated criteria for reporting qualitative research" (COREQ) will be followed in order to guarantee a comprehensive report of qualitative studies
Analysis of subgroups or subsets
A subgroup analysis considering gender, and resource setting, qualification of medical professionals and setting) developed or developing countries may be performed if the data extracted from the included studies is sufficient