Title: Perceived guideline clarity impacts guideline-concordant care for breast cancer screening
in women age 40-49
Version: 2 Date: 30 Nov 2022
Reviewer:  Lisa Parker
Reviewer's report:
Summary:
This paper reports on a qualitative interview study with primary care practitioners in Canada. It
explores PCP practices around breast screening for women 40-49 and seeks to understand the
influences on variation in PCP screening recommendations. The authors find that key factors
influencing PCP behaviour are their perceptions about clarity of guidelines and their practices
around deferring to patient preference.
Overall comments:
This is an important paper on a topical issue. I found that the main findings were a little buried
in the text which is a shame because the findings are important. From my reading of the paper,
the authors found that participants who said that guidelines lack clarity are likely to behave in
ways that do not accord with the guideline. This makes sense, since if the participants don’t quite
know what the guideline is saying, they won’t quite know how to act.  Specifically, the authors
found that these participants who are confused by the guidelines have discussions and referral
patterns that don’t match the guideline. Perhaps the authors could highlight this more strongly,
and maybe expand in the discussion about what this might mean for the patients (overdiagnosis
etc). In addition, as a reader I was interested to know whether the researchers found that lack
of guideline clarity was a common thread or dominant theme amongst the participants. I do
understand that this is a qual study and not necessarily representative, but it would be interesting
to know the authors’ sense about whether or not guideline clarity / lack of clarity is a significant
problem or just an issue for a minority of PCPs.
I would have like a stronger paragraph in the discussions about recommendations – eg there are a
few lines about improving guideline clarity but this could be expanded with additional references
or examples perhaps. And do the authors have anything specific to recommend around the theme
of deferral to patient preference and whether this is appropriate / if not how it might be changed?
I have some additional minor comments and suggested edits below – I found the tables hard to
read and would recommend some re-working for greater clarity.
Abstract:
The authors might like to reconsider the line “Population-based data reveal variation in primary
care professionals (PCPs) mammography rates in this age group, highlighting the need to
explore PCP screening perspectives and how this informs clinical behaviours.” The conclusion
is not valid since there may be other reasons why PCP mammography rates vary (PCP practice
location / demographics etc)
I found this line long and difficult to read: “Perceived guideline clarity (a lack of clarity
on guideline-concordant practices) moderated the extent to which the risk assessment and
discussion occurred; PCPs who perceived that guidelines recommended against routine
screening had greater knowledge of harms and stronger beliefs about capabilities to explain why
screening is not recommended routinely.” Are the authors talking about perceived guideline
CLARITY in this second half of the sentence or about PCP perception of the guideline
MESSAGE - do / don’t routinely screen
Introduction:
P 4 para 1 – the authors write that Radiology societies have published recommendations about
screening that cite updated research. Do the authors want to comment on whether there is any
controversy about these recommendations?
P 4 please spell out the OHIP acronym and explain for non-Canadian readers
Methods:
I would have liked more information on participant sampling, how participants were recruited,
selected etc. I note that ‘under-represented’ participants were purposively selected as the study
progressed - what were the criteria for selecting variation in participants?
Can the authors provide more detail about the interviews – eg face to face or phone;
professionally transcribed vs note taking etc
Can the authors write a line or two about their views, experiences and professional backgrounds.
There is a brief statement on p 11 but perhaps this could be fleshed out and/or added earlier
in the paper. This is helpful for readers to understand factors that might inform the researcher
approach. Can the authors also briefly describe how the interviewer introduced herself to the
participants to give added context for the reader.
Results:
Tables – I found it difficult to read and use these tables without referring back to the text. I
wonder if the authors can re-work the tables to provide more clarity about what they are trying
to show and say for the readers who are just focusing on the tables. For example, perhaps some
greater use of explanatory phrases rather than reliance on TDF based categories might be helpful.
In addition there were some parts of the table that didn’t seem to be reflected in the text, eg
Table 1. Behaviour 1: Risk Assessment - I can’t see where that the topic these 2 quotes refer
to is in the text? It’s an interesting topic – seemingly relating to PCP confusion about how to
assess risk and wanting more guidance on how to do that task.