098 Limitations in clinical practice guideline implementation in cancer care: feedback from routine use of a computerized decision support system (OncoDoc2) in breast cancer management

Background and objectives  In France, decisions on cancer patient management have to be taken in multidisciplinary staff meetings (MSMs) and should comply with clinical practice guidelines (CPGs). Computerized decision support systems (CDSSs) provide patient-specific recommendations and are considered to be tools suited to promoting CPG use and reducing variations in practice. At our hospital, breast cancer management decisions are taken during weekly senology MSMs and are based on CancerEst guidelines. OncoDoc2 is a CDSS providing a tailored care plan for each breast cancer patient. It was developed using CancerEst guidelines and was used in a before-after study in 2005–2006i to evaluate MSM decision compliance with CancerEst CPGs. Compliance rate during the ‘before’ period (6 months), when OncoDoc2 was not used, was measured on 226 decisions and was 79.2%. During the ‘after’ period (6 months), when OncoDoc2 was used in MSMs at decision-making (241 decisions), compliance rate increased significantly to 93.4% (p  Programme  For each clinical case discussed in a MSM, OncoDoc2 is used to display the therapeutic care recommended by CancerEst guidelines on a large screen. Decisions are tagged either ‘do comply’ or ‘do not comply’ with guidelines. Reasons have to be given for non-compliance and are categorized as follows: ‘special case’, ‘patient preference’, ‘MSM preference’, ‘changes in practice’, or ‘other’.  Results  Between February 2007 and September 2009, 1889 MSM decisions were analysed. Compliance rate was 90.3%. The main reasons for non-compliance were ‘special cases’ (34.2%) (eg, patients with BRCA1/2 mutations, pregnant women, the elderly) and ‘MSM preferences’ (33.2%). The reason was ‘patient preference’ (eg, patient refusing mastectomy or, on the contrary, requesting radical surgery) in 13.0% of cases, ‘changes in practice’ in 18.5%, and ‘other’ in 1.1%.  Discussion and conclusion  The compliance rate of MSM decisions was similar on routine OncoDoc2 use to the rate observed in the initial before-after study. Overall, 9.7% of decisions did not comply with guidelines. The contribution of ‘patient preference’ to this percentage cannot be predicted nor decreased. ‘Special cases’ could, in theory, be taken into account if the scope of CancerEst guidelines, and thus the CDSS knowledge base, were extended. The contribution of ‘changes in practice’ to non-compliance reflects a need to update the guidelines as medical knowledge evolves, and these cases of non-compliance are in fact eliminated at each update of the guidelines. The reason ‘MSM preference’ is given in cases that match the theoretical scenarios described in the guidelines but where interpretation of the whole medical picture is complex. In these cases, physicians evaluate the benefit/RR for each therapeutic option and jointly decide against strict compliance with recommendations. Their clinical judgement and experience prevail over regulated care.  In conclusion, our study has illustrated that 100% compliance with CPGs is a theoretical objective that needs to be adjusted to take into account special cases, patient preferences, and borderline cases that need interpretation by physicians.  iStudy partly supported by the French Haute Autorite de Sante (ANAES-2004-074).  Contexte  Aujourd9hui, la prise en charge des patients atteints de cancer doit, en France, etre decidee lors de reunions de concertation pluridisciplinaire (RCP) et se fonder sur les recommandations de pratique clinique (RPC). Parce qu9ils fournissent des conseils personnalises, les systemes informatiques d9aide a la decision (SAD) sont consideres comme des outils adaptes a la mise en œuvre des RPC et susceptibles de reduire la variabilite des pratiques. A l9hopital Tenon (Paris, France), les decisions de prise en charge du cancer du sein sont etablies sur la base du referentiel CancerEst lors de RCP hebdomadaires de senologie. OncoDoc2 est un SAD produisant un plan de prise en charge therapeutique personnalise pour chaque patiente. Le systeme a ete developpe a partir du referentiel CancerEst. OncoDoc2 a permis d’evaluer la conformite au referentiel CancerEst des decisions de RCP de Tenon au cours d9une etude interventionnelle avant/apresi en 2005–2006. Dans la periode sans intervention (6 mois), le taux de conformite etait de 79.2% pour 226 decisions. Dans la seconde periode (6 mois), l9utilisation d9OncoDoc2 en RCP s9est accompagnee d9une augmentation significative de la conformite (p  Programme  Lors des RCP, et pour chaque dossier discute, OncoDoc2 est projete sur un grand ecran de facon a afficher la proposition du plan therapeutique recommande par le referentiel. Les decisions prises par les medecins de la RCP sont typees comme conformes ou non selon qu9elles suivent ou non le referentiel. Les decisions non conformes doivent etre justifiees. Elles sont categorisees en cas particulier, choix patient, choix RCP, evolution des pratiques et autre raison.  Resultats  Entre fevrier 2007 et septembre 2009, 1889 decisions de RCP ont ete analysees. Le taux de conformite est de 90,3%. Les decisions non conformes sont principalement les cas particuliers (34,2%, p. ex. presence de mutations BRCA, femmes enceintes ou âgees…), et les choix RCP (33.2%). Les choix patient (p. ex. patiente refusant la mastectomie ou desirant au contraire un traitement radical) representent 13.0%, l’evolution des pratiques 18.5% et les autres raisons 1.1%.  Discussion  Le taux de conformite observe en utilisant OncoDoc2 en routine s9est maintenu au meme niveau que celui atteint lors de l’etude initiale. Sur les 9.7% de decisions non conformes, la part revenant aux preferences patiente ne peut etre ni anticipee, ni reduite. Les cas particuliers pourraient theoriquement etre pris en charge en etendant le champ d9application du referentiel et donc le SAD. L’evolution des pratiques signe le processus de vieillissement du referentiel au fur et a mesure de l’evolution des connaissances et donne lieu a des cas de non conformite elimines a chaque reactualisation du referentiel. Enfin, les choix RCP se produisent pour les cas dont l9interpretation est delicate. Bien que ces patientes correspondent exactement aux scenarios theoriques prevus par le referentiel, les medecins decident de ne pas suivre ce qui est recommande sur le plan strictement formel apres evaluation du rapport benefice/risque des differentes propositions therapeutiques. Ces cas decrivent le territoire ou l9autonomie de decision des medecins et leur experience prennent le pas sur la regulation des soins. Cette experience illustre les limites a une conformite de 100%, objectif theorique qu9il convient de moduler pour tenir compte des cas particuliers, des preferences patient et des cas limites qui doivent etre interpretes par les medecins.  iEtude partiellement financee par la Haute Autorite de Sante Francaise (ANAES-2004-074).