Table 5 Facilitators and barriers of guideline implementability as perceived by Family Physicians: USABILIY

Simplicity (N = 14)

Simple (N = 4)

● Keep it simple and straightforward {FG1-P3}

Too much information (N = 3)

● It’s not helpful if the guideline requires some reading, and people have varying levels of patience and time to read around the recommendations to find out how they are supposed to implement the recommendation {I-5}

● Guidelines have to be simple and straightforward, if it’s complicated I’m not going to remember it anyway and won’t look at it {FG2-P2}

Too complicated or difficult to follow (N = 4)

● Some guidelines are very complex (i.e., the ones with 30 recommendations) and written above the practice level, so will not go back to it because its overwhelming and a bombardment of information - no time to fit into brain. There should be 5 of the most important things that should be given to family physicians (by specialists) to remember {I-1}

If too simplistic (N = 2)

● Guidelines are meant to simplify but sometimes they become too simplistic {FG3-P3}

Complicated clinical questions (N = 1)

● We struggle with the complex management questions (e.g., if there is 4 second degree relatives but no first degree relative when considering mammography at age 40 instead of age 50) {I-10}

Applicability (N = 11)

Relevant to primary care practice (N = 1)

● Answers questions that are relevant to primary care and thus clinically useful {I-10}

Does not fit with practice (N = 5)

● What they tell you to do and what you actually do in your practice never seem to match up {I-8}

Should make a difference for patients (N = 1)

● So, I think one of the things that I would want to see is if it makes a difference to my patient you know, just having a lower level or having everybody with a hemoglobin A1C of whatever, it doesn't always translate into healthier patients {FG1-P3}

Does not apply to patient population (N = 3)

● Applicability to primary care population is a barrier; I think it's also that specialists see a particular population and they are coming from a particular viewpoint. But then, as a primary care physician, your population is going to be a little bit different, so I think that's where the challenge lies {I-9}

Should be meaningful (N = 1)

● The number needed to treat has to be meaningful to make it implementable (putting 1000 people on beta blockers to save 1 MI is not implementable) {FG1-P3}

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Updating (N = 8)

Having the most up-to-date information (N = 1)

● One quality that would influence my decision making is guidelines that are current and have the most up-to-date information {I-2}

Constantly changing guidelines (N = 4)

● Changing/update of evidence forces changes to routine practice that is difficult to explain to patients {FG2-P1}

Guidelines that build on previous updates (N = 1)

● Guidelines that are helpful are those that build on previous updates (e.g., blood pressure and hypertension guidelines), the ones that build on what you already know {I-9}

Guidelines that are not updated (N = 2)

● There are also recommendations which don’t seem to fit with what I know of the latest evidence, where I start wondering, okay just how up to date is this thing, I mean that’s another barrier to it. {I-1}

Ease of use (N = 6)

Quick to use (N = 4)

● Guidelines should be quick to use because family physicians' approach to seeing patients is different than specialists - less time to reflect on how to manage {I-3}

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Easy to remember (N = 2)

● Something that sticks in my mind and can be used on a day-to-day basis {I-1}

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Consistency (N = 5)

Consistent (N = 1)

● I mean we forget about the rest of the world {Laughter} I mean you have guidelines from every country but at least in Canada they're getting some consistency in terms of you know, the big diseases which is nice {FG4-P2}

Inconsistent or conflicting (N = 4)

● Recommendations that are not firm and sort of all over the place (e.g., one guideline states to exercise 30 minutes/day while another states 5 minutes/day); this was a big issue when hypertension and cholesterol guidelines did not sync with diabetes. {I-1}

Flexibility (N = 3)

Flexible (N = 3)

● Guidelines have to be flexible; Sometimes there is no flexibility when they say you can do this and then next step is first line, second like – this should be fairly straightforward but in reality it’s not always easy to do that {FG1-P3}

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● Guidelines should allow you to be creative and let you think outside of the box in case something doesn't fit in smoothly {I-2}