title: Practice patterns for the management of hepatic metastases from colorectal cancer: a mixed methods analysis.
abstract: OBJECTIVE
  The optimal management of colorectal cancer liver metastases (CRC-LM) has changed during the past two decades. However, clinical practice lags behind best evidence recommendations. We sought to characterize the gap between current practice and best evidence for the management of these patients and to identify barriers that hamper effective utilization of metastasectomy.
  
  
  METHODS
  A mixed-methods approach was used. A survey was mailed to all general surgeons (GS) and medical oncologists (MO) in Ontario, Canada. Domains examined included: physician/practice characteristics, indications for hepatectomy, use of multi-modality therapy and referral patterns. Physician focus groups were conducted that explored issues relating to access to care.
  
  
  RESULTS
  The survey was mailed to 942 physicians with a response rate of 68 % (n = 348; GS n = 295, 69 %; MO n = 53, 63 %). Current practice patterns demonstrated that 97 % of physicians refer patients with low tumor burden (e.g., solitary CRC-LM), but referral rates for hepatectomy decreased as the tumor burden increased. Physicians still consider extrahepatic disease as a strong contraindication to metastasectomy. Barriers to care included: economic, time, and resource constraints; lack of physician engagement, local medical expertise, and high-quality guidelines. Multidisciplinary cancer conferences were identified as an enabler of clinical care and a potential platform for the acquisition of new medical knowledge.
  
  
  CONCLUSIONS
  Current management of CRC-LM does not reflect best evidence. Patients who may benefit from surgery are not being referred for metastasectomy. We have identified an evidence-practice gap at the level of physician, which should be targeted with novel quality improvement strategies.
authors.affiliation: Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada. alice.wei@uhn.ca
authors.forename: Alice C
authors.initials: AC
authors.lastname: Wei
authors.forename: Lakhbir
authors.initials: L
authors.lastname: Sandhu
authors.forename: Katharine S
authors.initials: KS
authors.lastname: Devitt
authors.forename: Anna R
authors.initials: AR
authors.lastname: Gagliardi
authors.forename: Erin D
authors.initials: ED
authors.lastname: Kennedy
authors.forename: David R
authors.initials: DR
authors.lastname: Urbach
authors.forename: Steve
authors.initials: S
authors.lastname: Gallinger
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
mesh_terms: D002983:Clinical Competence; D015179:Colorectal Neoplasms / Q000473:pathology*; D003131:Combined Modality Therapy; D000075202:Contraindications; D019317:Evidence-Based Medicine; D005260:Female; D017144:Focus Groups; D013502:General Surgery / Q000706:statistics & numerical data*; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008495:Medical Oncology / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D009864:Ontario; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D019037:Urban Health Services / Q000706:statistics & numerical data