title: A mixed methods approach to understand variation in lung cancer practice and the role of guidelines.
abstract: BACKGROUND
  Practice pattern data demonstrate regional variation and lower than expected rates of adherence to practice guideline (PG) recommendations for the treatment of stage II/IIIA resected and stage IIIA/IIIB unresected non-small cell lung cancer (NSCLC) patients in Ontario, Canada. This study sought to understand how clinical decisions are made for the treatment of these patients and the role of PGs.
  
  
  METHODS
  Surveys and key informant interviews were undertaken with clinicians and administrators.
  
  
  RESULTS
  Participants reported favorable ratings for PGs and the evidentiary bases underpinning them. The majority of participants agreed more patients should have received treatment and that regional variation is problematic. Participants estimated that up to 30% of patients are not good candidates for treatment and up to 20% of patients refuse treatment. The most common barrier to implementing PGs was the lack of organizational support by clinical administrative leadership. There was concern that the trial results underpinning the PG recommendations were not generalizable to the typical patients seen in clinic. The qualitative analysis yielded five themes related to physicians' decision making: the unique patient, the unique physician, the family, the clinical team, and the clinical evidence. A dynamic interplay between these factors exists.
  
  
  CONCLUSIONS
  Our study demonstrates the challenges inherent in (i) the complexity of clinical decision making; (ii) how quality of care problems are perceived and operationalized; and (iii) the clinical appropriateness and utility of PG recommendations. We argue that systematic and rigorous methodologies to help decision makers mitigate or negotiate these challenges are warranted.
authors.affiliation: Department of Oncology, McMaster University, Juravinski Hospital Site, 1280 Main Street West, JHCC G207, L8S 4L8 Hamilton, ON, Canada. mbrouwer@mcmaster.ca.
authors.forename: Melissa C
authors.initials: MC
authors.lastname: Brouwers
authors.forename: Julie
authors.initials: J
authors.lastname: Makarski
authors.forename: Kimberly
authors.initials: K
authors.lastname: Garcia
authors.forename: Saira
authors.initials: S
authors.lastname: Akram
authors.forename: Gail E
authors.initials: GE
authors.lastname: Darling
authors.forename: Peter M
authors.initials: PM
authors.lastname: Ellis
authors.forename: William K
authors.initials: WK
authors.lastname: Evans
authors.forename: Mita
authors.initials: M
authors.lastname: Giacomini
authors.forename: Lorraine
authors.initials: L
authors.lastname: Martelli-Reid
authors.forename: Yee C
authors.initials: YC
authors.lastname: Ung
mesh_terms: D001291:Attitude of Health Personnel; D002170:Canada; D002289:Carcinoma, Non-Small-Cell Lung / Q000628:therapy*; D003657:Decision Making; D006801:Humans; D008175:Lung Neoplasms / Q000628:therapy*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research