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Table 2 Domains describing barriers and facilitators to decision aid implementation

From: Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome

TDF domain Specific belief Barrier or facilitator Representative quotes (interview ID) N
Knowledge I need to see the evidence supporting the guideline before adopting it into practice B “it’s not clear to me that a zero on this score is associated with less than 5% chance of acute aortic syndrome. And then the same applies to each subsequent risk tier.” (5)
“I think a validation of study of the decision aid would have to be done to convince people to use it, as opposed to using it off the bat with no validation study. But if the validation study was showing its utility then I think I would be amenable to using it.” (7)
  I am not convinced of the utility of D-dimer in screening for AAS B “Do I d-dimer all of them [moderate risk]? I can't say that I do. I probably do other tests that would decrease my suspicion before doing a d-dimer.” (4) 5
  The guidelines align with my understanding of the evidence for AAS risk factors F “I can't think of any additional factors that would prompt me to investigate for dissection other than what we already listed…it’s easy because it already fits with my mental model of aortic dissection.” (1) 4
  The clinical decision aid must be validated before I would use it B “You wonder about defensibility, as it is, especially … without, like, something like a randomized control trial to support it.” (6) 3
Behavioural regulation Integrating new information into practice is cognitively challenging B “I would like to see evidence that stimulant use and hypertension are/are not important risk factors for AAS…sometimes it’s just hard to unlearn those things” (6) 1
Social influences Guidelines help justify clinical decisions to colleagues F “Yeah, for sure [a guideline can] help make your case; speaking to other consultants and talking about ‘hey, have you heard of this new guideline that is actually supported by a bunch of other radiologists or vascular surgeons.’” (2) 2
  Decision aids support shared decision-making with patients F “I might say ‘we can do a d-dimer, and if it's negative [...] we've essentially ruled it out’. And it would be nice to be able to give them a number to say ‘if your d-dimer is negative, in a population of 100 people who are presenting similarly to you, only 0.5 percent of people are missed’, or whatever that number might be. I think for the patient to be engaged in that conversation, I need those numbers or I need the evidence to be able to have that conversation with them.” (5) 2
  More likely to use guidelines that have been endorsed by peers F “Getting the stuff published is usually successful, particularly studies that are published in decent journals, and decent meaning, respected journals.” (3)
“Getting CAEP to endorse a set of rules is very influential in getting them incorporated, you know, when a group of emergency positions…a group that represents emergency physicians in Canada publishes the stuff, discusses it and says this is a standard of care—that's obviously very influential.” (3)
“The fact that my colleagues aren’t also using it. I recently sort of polled like, a handful of people, and none of them are using d-dimer except for one, um, to help rule out aortic dissection in, like, low to medium risk patients. That is always a cause for concern–when you are doing something that is different than your colleagues.” (6)
Environmental context and resources The guidelines will not be followed when CTs are readily available B “I don't think, honestly, they're going to be going for a decision aid, they’re going to say, get me the CT, because it's so easy for us.” (8) 1
  The guidelines will benefit small centers in particular because it may reduce the need for patient transport F “A decision rule that prevents people from needing complex investigations can be super useful particularly if you don't work in a major center.” (3) 3
Reinforcement I am more likely to follow the guideline if it is shown to reduce resource use F “in the rural facility this is a really important opportunity to minimize transfer. So the effect on my practice, based on where the patient’s hanging out, whether we’re in [rural community] or something, I lose a nurse, I lose my physician assistant, if I send my patient out for CT scan.” (9) 2
Social/ professional role and identify Clinical gestalt outperforms guidelines in clinical decision making B “I think a lot of times too with these decision aids, a lot of times it gets shown that clinical gestalt and experience is worth just as much as those, or perform just as well.” (8) 2
Beliefs about capabilities Guidelines facilitate my decision making F “If I am uncertain and the patient is in a moderate risk category, then I would, I like the idea. I like the way this decision will makes you perhaps do a D dimer first as a screening test for CTA.” (3) 5
Beliefs about consequences The clinical decision aid is likely to be very sensitive F “In all honesty I think your decision aid will make people happy, because it’s going to be hard to miss people, I think” (8) 2
  Guidelines will lead to an increase in imaging B “I think this may be one of these decision aids that will lead to increased testing, because it’s very easy to have one of the symptoms you’re talking about.” (8)
“That heightened my concern about having a lot of positive d-dimers that then result in CT aortas being done… I would be worried that there would be a lot of false positives, which would lead to a lot more imaging being done.” (5)
Emotion A clinical decision aid can help reduce anxiety around decision-making in AAS F “Cause right now I'm relying on my clinical gestalt. So it would be nice to have an evidence based tool to support my clinical decision making.” (5) 2
Optimism Some cases of AAS will be missed even if the guidelines are followed B “Even if that same patient like my colleague had the other day came in again, I would probably be fooled again.” (1) 2
Goals The guidelines will improve my ability to risk-stratify patients F “And I think the dimer offers me one more step to be able to risk-stratify these patients. Because otherwise, you either don’t do the test or you do the test-- like the CT--and it’s kind of like, well, we have another option now.” (9) 2