Introduction

Breast cancer is the most common cancer in women with 2.3 million new cases estimated in 2020, accounting for 11.7% of all cancers [1]. It is the fifth leading cause of cancer mortality worldwide, with 685,000 deaths [1]. Breast cancer diagnosis is more frequent in developed countries [2]. Controlling and preventing breast cancer is an important priority for health policy makers [3].

Treatment procedures have rapidly evolved over recent years. As new and precise diagnosis strategies emerged, early treatment and prognosis of breast cancer patients have shown great progresses [4]. Advances in breast cancer screening and treatment have reduced the mortality of breast cancer across the age spectrum in the past decade [5,6,7]. Although the use of research evidence can improve professional practice and patient-important outcomes, considering also the huge volume of research evidence available, its translation into daily care routines is generally poor [8, 9]. It is estimated that it takes an average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice [10].

Clinical Practice Guidelines (CPGs) provide recommendations for delivering high quality healthcare [11, 12]. However, the impact of CPGs depends not only on their quality, but also on the way and the extent to which they are used by clinicians in routine clinical practice. Large overviews show that approximately 50% of patients receive from general medical practitioners treatments which differ from recommended best practice [13,14,15,16]. In the area of breast cancer, previous systematic reviews have shown that compliance with breast cancer CPGs [17], as well as for other types of cancer [18,19,20], remains suboptimal. A recent systematic review from our research group [21] found large variations in providers´ compliance with breast cancer CPGs, with adherence rates ranging from 0 to 84.3%. Sustainable use of CPGs is also notably poor: after 1 year of their implementation, adherence decreases in approximately half of the cases [22].

Suboptimal compliance with CPGs recommendations could increase healthcare costs if healthcare resources are overused (e.g., overtreatment, overuse of diagnosis or of screening techniques); but also, if they are underused (i.e., increased costs to cover the additional health care needs that people may face with worsening conditions due to under-used resources). Available evidence suggests that outcomes may improve for patients, healthcare professionals and healthcare organizations if decision-makers adhere to evidence-based CPGs [23, 24]. This is supported by a recent meta-analysis from our group [25], which suggests that compliance with CPGs is probably associated with an increase in both, disease-free survival (hazard ratio (HR) = 0.35 (95% CI from 0.15 to 0.82)) and overall survival (HR = 0.67 (95% CI 0.59 to 0.76). Developing interventions to support clinician uptake of breast cancer CPGs is therefore essential for improving healthcare quality and patient important outcomes. Although several interventions to support compliance with breast cancer CPGs have been proposed, no previous study has systematically examined their characteristics and effects.

The aim of this systematic review is to characterize and evaluate the impact of available interventions to support healthcare providers’ compliance with CPGs in breast cancer care.

Methods

Design

We conducted a systematic literature review adhering to the PRISMA reporting guidelines [26] (PRISMA 2020 Checklist available at Additional file 1). In this review, we addressed the following two questions: (1) What type of interventions have been used to support healthcare professionals´ compliance with breast cancer CPGs? and; (2) What type of interventions can effectively support healthcare professionals’ compliance with breast cancer CPGs? We registered the protocol in the international prospective register of systematic reviews (PROSPERO registration number CRD42018092884).

Searches

We searched for systematic reviews and original studies in MEDLINE (through PubMed) and Embase (through Ovid) using predefined search strategies from inception to May 2021 designed and implemented by an information specialist (IS) from the Iberoamerican Cochrane Centre (IS). The search strategies (available in Additional file 2) combined MeSH terms and keywords.

Study selection

We applied the following inclusion criteria:

  • Population: healthcare professionals providing health services related to the prevention or management of breast cancer. All types of healthcare professionals, and from any setting were included.

  • Intervention: interventions explicitly aimed at supporting or promoting healthcare professionals’ compliance with available breast cancer CPGs. Such guidelines may address any specific aspect of breast cancer care, including screening, diagnosis, treatment, surveillance or rehabilitation.

  • Comparator: any comparator, including also studies not using a comparator group.

  • Outcome: quality of breast cancer care (based on healthcare professionals’ compliance rate with breast cancer CPGs recommendations, but also on their knowledge, attitudes or self-efficacy concerning such recommendations); intervention implementation (fidelity, reach, implementation costs), and; patient health-related outcomes (e.g., survival).

We included experimental (randomized controlled and non-randomized controlled trials), observational (before-after, cohort, case-control, cross-sectional, and case studies), and qualitative or mixed-methods studies. Due to constrained resources, we only included studies published in English. One author (of IRC, DC, APVM) screened the search results based on title and abstract. A second author (ENG, LN, ZSP, EP, DC, APVM, GPM) independently reviewed 20% of all references. Two authors independently assessed eligibility based on the full text of the relevant articles. Disagreements were discussed (involving a third author when needed) until consensus was reached.

Data extraction

One author (ENG, IRC LN, ZSP, EP, DC, APVM, GPM) extracted the following data about the characteristics and results of the included studies using an ad hoc data extraction form which had been piloted in advance: publication year, study design (e.g., randomized controlled trial), study location, setting, number of participants, aim of the study, type of breast cancer guideline (e.g., breast cancer screening), type of intervention (e.g., computerized decision support systems), and outcome(s) assessed (e.g., compliance rate). A second author (ENG, IRC LN, ZSP, EP, DC, APVM, GPM) cross-checked the extracted data for accuracy.

Quality assessment

We used the following tools to determine the risk of bias of the included studies: the Cochrane Collaboration tool for assessing risk of bias in randomized trials (RoB I) [27], the ROBINS I tool for non-randomized controlled before-after studies [28], the Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group [29], the Newcastle-Ottawa scale for cohort studies [30], the AXIS tool for cross-sectional studies [31], and the MMAT tool [32] for mixed methods studies. The specific criteria included by each of these tools are available in Additional file 3. One author determined the risk of bias of the included studies, and a second author cross-checked the results for accuracy. Disagreements were solved with support from a senior systematic reviewer.

Data synthesis

We described the characteristics and the effects of the interventions narratively and as tabulated summaries. Findings are synthesized by type of intervention. We applied the Cochrane Effective Practice and Organization Care Review Group (EPOC) [33] taxonomy to classify our findings according to the types of interventions identified. Whereas for the characterization of the interventions we included all the publications identified meeting our eligibility criteria (irrespectively of their design); for the evaluation of the effectiveness of the interventions we focused only on those studies following a suitable design for such purpose [34]: randomized controlled trials (RCTs), controlled before-after studies, non-randomized controlled trials, and interrupted time series. Although we planned to conduct a meta-analysis on the impact of the interventions on compliance rates, this was finally not feasible due to the inconsistent and poor reporting. Instead, we provide a graphical quantitative description of the compliance rates before and after the implementation of the interventions.

Certainty of the evidence

Following the GRADE approach [35], we rated the certainty of evidence as high, moderate, low or very low, taking into consideration risk of bias, imprecision, inconsistency, indirectness, and publication bias. This was done by one researcher. and cross-checked by a second reviewer.

Results

Search results

The eligibility process is summarized in a PRISMA flowchart (Fig. 1). We retrieved a total of 9065 unique citations from database searches, which were reviewed (through screening by title and abstract) along with 416 additional references identified from the thirteen systematic reviews also identified. We selected 145 references for full text revision, from which 35 primary studies (reporting on 24 different interventions) were finally included in our systematic review [36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70].

Fig. 1
figure 1

PRISMA flowchart

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Characteristics of the included studies

The characteristics of the included studies are summarized in Table 1 and described in detail in Additional file 4. Most (86%) were published from 2000 onwards. The studies were conducted in six countries: 15 (42%) were conducted in USA [37, 44,45,46, 49,50,51, 53,54,55,56,57,58, 60, 70], 12 (34%) in France [38,39,40,41,42,43, 63,64,65,66,67,68], 3 (9%) in the Netherlands [52, 62, 69], and 3 (9%) in Canada [36, 59, 61]. The remaining two studies were conducted in Australia [47], and Italy [48]. Eleven studies described interventions to support compliance with guidelines on diagnosis and treatment [41, 43, 52, 56, 64,65,66,67,68,69,70], 9 focused on treatment only [38,39,40, 42, 47,48,49, 62, 63], 5 on diagnosis only [45, 51, 58,59,60], and 7 on screening [36, 37, 46, 50, 54, 57, 61]. Six studies were randomized controlled trials [37, 45, 50, 51, 54, 60], four were non-randomized controlled trials [46, 57, 58, 63], eight non-controlled before-after studies [42, 49, 53, 55, 59, 62, 65, 69], one prospective cohort study , three cross-sectional studies [44, 47, 56], one mixed-methods [36] and twelve case studies [38,39,40,41, 43, 48, 52, 61, 64, 66,67,68].

Table 1 Characteristics of the included studies (N=35)
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Thirty of the 35 studies (85%) evaluated the impact of the interventions on compliance rate [36,37,38,39,40,41,42,43, 45,46,47,48,49,50,51, 53,54,55,56, 58,59,60, 62, 63, 65,66,67,68,69,70]. Four studies [43, 46, 50, 57] evaluated the impact on determinants of behavior change related outcomes (providers’ knowledge, attitudes, and self-efficacy about the CPGs recommendations). Two studies evaluated intervention adoption and fidelity [36, 44]. No study evaluated the impact of the intervention on patient outcomes, and only one study [44] evaluated the costs of implementing the interventions.

Characteristics of the interventions to support compliance with breast cancer clinical practice guidelines

Table 2 describes the characteristics of each type of intervention. Twelve studies described two different interventions consisting in the implementation of computerized decision support systems [38,39,40,41,42,43, 48, 64,65,66,67,68], 7 described 6 different educational interventions targeting health care professionals [44, 50, 55, 57,58,59, 63], 9 described 9 multifaceted interventions [36, 37, 46, 49, 51, 53, 54, 60, 62], and two studies described two audit and feedback interventions [47, 69]. The rest of the studies described interventions based on: implementation of clinical pathways [56], integrated knowledge translation systems [61], medical critiquing system [52], medical home program [70], and reminders to providers [45].

Table 2 Characteristics of the interventions identified to support healthcare providers´ compliance with guideline recommendations for breast cancer
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Computerized decision support systems

The use of computerized decision support systems to promote compliance with breast cancer CPGs was described in 12 studies [38,39,40,41,42,43, 48, 64,65,66,67,68]. Eleven of them reported the same intervention, which consisted of a system developed in France called OncoDoc [38, 40–43, 64–68). OncoDoc is a computerized clinical decision support system that provides patient-specific recommendations for breast cancer patients according to CancerEst (local) CPGs [71]. A study conducted in Italy reported on the development of a similar system, the OncoCure CDSS [48].

Educational interventions

Seven studies described educational interventions targeting healthcare providers to promote compliance with breast cancer CPGs [44, 50, 55, 57,58,59, 63]. One intervention consisted in the provision of academic detailing on breast cancer screening (based on the American Cancer Society guidelines for the early detection of BC) among primary care physicians in an underserved community in the USA [50]. An intervention in seven hospitals in France consisted in monthly meetings where local opinion leaders presented the relevant sections of the CPGs, which were subsequently sent to all the participating physicians who were expected to use them in their practice [63]. Another intervention consisted in a comprehensive continuing medical education package to address pre-identified barriers to guideline adherence. The intervention followed a multimethod approach to physician education including CME conferences, physician newsletters, CBE skills training, BC CME monograph, “question of the month” among hospital staff meetings, primary care office visits, and patient education materials [57, 58]. An educational intervention to improve compliance with radiological staging CPGs in early breast cancer patients [59] consisted of multidisciplinary educational rounds, presenting the Cancer Care Ontario Practice Guidelines [72]. Another intervention, aimed to support compliance with recommendation against serum tumor marker tests and advanced imaging for BC survivors who are asymptomatic for recurrence, consisted in academic detailing for oncologists at regular meetings [55]. Another intervention [44] consisted in an online course to learn to implement and deliver the Strength after Breast Cancer (SABC) guidelines (with recommendations about rehabilitative exercise for breast cancer survivors).

Audit and feedback interventions

We identified two audit and feedback interventions [47, 69]. One consisted in sending hospitals a written report with regional benchmark information on nine performance indicators measuring the quality of care based on breast cancer national guidelines [69]. Healthcare professionals attended sessions twice a year, where an anonymous benchmark was presented for each hospital score compared with the regional mean and the norm scores. Another intervention [47] audited patients’ medical records according to four agreed indicators. Information from the audit forms was entered into a database, which allowed individualized reports for each participating clinician, providing detailed feedback about their practice, with comparisons across the group and against the agreed criteria.

Other types of single component interventions

Five studies described other strategies to promote compliance with breast cancer CPGs [45, 49, 52, 56, 61, 70]. One intervention consisted on a microcomputer tickler system on the ordering of mammograms [45]. The system displayed the date of the last mammogram ordered in the “comments” section of the encounter form for each visit. An intervention to support compliance with CPGs follow up recommendations in low-income breast cancer survivors [70] consisted in the implementation of a medical home program to support primary care case management. Providers and networks participating in this program received a payment per eligible patient per month for care coordination. Another intervention consisted in the implementation of new clinical pathways supplemented by clinical vignettes [56]. Another intervention consisted in an integrated knowledge translation strategy to be used by guideline developers to improve the uptake of their new CPGs on breast cancer screening [61]. This integrated knowledge translation strategy was based on the Knowledge to Action Framework [73], and involved the identification of barriers to knowledge use. An intervention to support compliance with the Dutch breast cancer guideline [52] consisted of a medical critiquing system (computational method for critiquing clinical actions performed by physicians). The system aimed at providing useful feedback by finding differences between the actual actions and a set of ‘ideal’ actions as described by a CPG.

Multifaceted interventions

We identified nine multifaceted interventions [36, 37, 46, 49, 51, 53, 54, 60, 62]. One intervention to increase compliance with mammography screening [37] consisted of (i) audit results and a comparison with the network benchmark; (ii) academic detailing of exemplar principles and information from the medical literature; (iii) services of a practice facilitator for 9 months who helped the practitioners design their interventions and facilitate “Plan, Do, Study, Act” processes; and iv) information technology support. In another intervention [60] to increase screening mammography, primary care providers received (i) a fact sheet providing current information on screening mammography for older women; (ii) telephone follow-up of any questions, and; (iii) copies of a simply written pamphlet on mammography that they could distribute to patients. Another intervention [54] consisted of biannual feedback to primary care providers regarding compliance with cancer screening CPGs and financial bonuses for “good” performers. Feedback reports documented a site’s scores on each screening measure and a total score across all measures, as well as plan-wide scores for comparison. Another intervention [51] consisted of an educational intervention accompanied by cue enhancement using mammography chart stickers, and by feedback and token rewards. Another intervention [46] included (i) use of standardized patients to observe and record healthcare professionals’ performance followed by direct feedback; (ii) newsletters to inform healthcare providers about screening methods; (iii) posters and cards presenting key points about CBE and the importance of routine screening mammograms, and; (iv) patient education materials. An intervention to improve compliance with new CPGs by the American Society for Radiation Oncology (ASTRO) on the proper use of hypofractionation [49] consisted in implementing five consensus-driven and evidence-based clinical directives to guide adjuvant radiation therapy for breast cancer. Prospective contouring rounds were instituted, wherein the treating physicians presented their directive selection and patient contours for peer-review and consensus opinion. Another intervention combined audit and feedback and education to providers to increase compliance with breast cancer treatment guidelines [62]. Repeated feedback on the performance of the chemotherapy administration, timing and dosing were given to the participants. The feedback consisted of a demonstration of variation in performance between the different hospitals and the region as a whole. The educational component consisted in four consecutive sessions of discussion about relevant literature that became available in that period regarding chemotherapy dose intensity, sequencing of radiotherapy and the importance of adequate axillary lymph node clearance.

An intervention to promote compliance with new National Comprehensive Cancer Network guidelines from routine testing to omission of ordering complete blood cell count and liver function tests in patients with early breast cancer [53] involved (i) provision of educational materials; (ii) audit and feedback; (iii) certification; (iv) patient education; (v) financial incentives and (vi) implementation of alerts in the electronic medical records. Another intervention to promote breast cancer screening CPGs [36] included (i) printed educational materials with the recommendations for breast cancer mammography, (ii) printed educational materials with CPGs recommendations for clinical breast exams and breast self-exams, and (iii) video (12 min) directed at clinicians, exploring strategies for patient discussion around breast cancer screening issues.

Risk of bias

The risk of bias was judged as low in five studies [45, 53, 54, 59, 70], moderate in ten [36, 37, 42, 44, 47, 56,57,58, 62, 63], and high in five [46, 49, 50, 55, 65]. In four studies [51, 52, 60, 69] the risk of bias was unclear since there was not enough information available to determine potential biases. We did not assess risk of bias for case studies, due to the lack of appropriate tools available. A detailed description of the risk of bias of the included studies, excluding case studies, is available in Additional file 3.

Impact of the interventions

Six RCTs [37, 45, 50, 51, 54, 60] and four controlled before-after studies [50, 57, 58, 63] examined the effectiveness of four provider educational interventions, one intervention based on the use of provider reminders, and five multifaceted interventions. In nine of these interventions (90%), the ultimate goal was to improve compliance with breast cancer screening guidelines. Compliance was uniformly measured in terms of mammography rates (e.g., proportion of eligible women undergoing a mammography screening for breast cancer). Except one multifaceted intervention [54], the interventions consistently showed relevant beneficial effects (Fig. 2).

Fig. 2
figure 2

Compliance rate with guideline recommendations before and after the implementation of the identified interventions

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Impact of educational interventions

Four studies evaluated the effectiveness of educational interventions targeted to healthcare providers [50, 57, 58, 63]. A randomized controlled trial showed that the intervention improved recommendation of mammography (odds ratio (OR) 1.85, 95% CI 1.25–2.74) and clinical breast examination (OR 2.13, 95% CI 1.31–3.46) in female patients aged 40 and over [50]. One controlled before-after study showed significant (p < 0.05) improvements in providers’ knowledge, attitudes and self-efficacy towards the new CPG screening recommendations [57], whereas another controlled before-after study reported a significant improvement in the number of reported mammography referrals of asymptomatic women aged 50 to 75 years in the intervention group but not in the control group [58]. A controlled before-after study observed an improved compliance to diagnostic and treatment CPG recommendations in the intervention group (from 12% before the intervention to 36% post-intervention; P < 0.001), whereas no significant improvements were observed in the control group [63].

Impact of provider reminders

A randomized controlled trial [45] showed that a microcomputer-generated reminder system for ordering mammograms improved compliance with mammography guidelines: 27% (170/639) in the intervention vs 21% (128/623) in the control group (OR = 1.40 (95%CI = 1.01 to 1.82); p = 0.011) after 6 months follow-up.

Impact of multifaceted interventions

Five studies examined the impact of multifaceted interventions. A randomized controlled trial observed that, in comparison with usual care, a multifaceted intervention (including audit and feedback; provider education; information technology support) increased the proportion of women offered a mammogram (38% vs 53%), and the proportion of women with a recorded mammogram (35% vs 52%) [37]. Another trial observed that a multifaceted intervention (comprising provider education and patient education through pamphlets), did not improve compliance with screening mammography guidelines in the overall sample, but produced significant improvements in specific vulnerable subgroups (elderly, lower educational attainment, black ethnicity and with no private insurance) [60]. A randomized controlled trial observed that a multifaceted intervention (audit and feedback plus financial incentives) doubled screening rates both in the intervention and control groups, with no statistically significant differences observed between groups [54]. A trial examining a multifaceted intervention (provider education, cue enhancement plus feedback, and token rewards) observed that mammography compliance rates significantly improved (p < 0.05) in the intervention (62.8%) in comparison with the control (49.0%) group [51]. A controlled before-after study observed that a multifaceted intervention (including audit and feedback, patient and professional education) improved the demonstration of breast cancer screening, with significantly more women older than 50 receiving mammograms in the intervention than in the comparison group [46].

Certainty of evidence

The results from the assessment of the certainty of evidence concerning the impact of the interventions on compliance with breast cancer CPGs is available in Additional file 5. Based on GRADE criteria, we rated the certainty of evidence as “low” for the four educational interventions targeting healthcare providers. This was due to very serious risk of bias, for which we downgraded the level of evidence two levels. For the only intervention identified consisting in a reminder system for healthcare providers, we rated the certainty of evidence as “moderate” (downgrading one level due to serious indirectness). For the five multifaceted interventions, we rated the evidence as “low”, due to serious risk of bias, and serious inconsistency.

Discussion

Main findings

In this systematic review, we identified 35 studies describing and evaluating the impact of interventions to support clinician compliance with breast cancer CPGs. We described a range of different types of interventions to support adherence of healthcare professionals to breast cancer CPGs. We observed that there is low quality evidence that educational interventions targeted at healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality of evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality of evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified is uncertain, given the study designs available (e.g., cross-sectional, uncontrolled before-after or case studies). There is very limited data on the costs of implementing these interventions.

Strengths and limitations

The main strength of this systematic review is that it addressed a highly relevant question, and provided much needed evidence to help improve providers’ compliance with breast cancer guidelines globally. An additional strength is that, contrary to previous systematic reviews, ours was not limited to experimental studies. By including observational, and qualitative and mixed-methods studies, we were able to provide a richer characterization of the available interventions.

This review has several limitations. First, we restricted the bibliographic searches to peer-reviewed publications in English language only. This may have resulted in failing to identify additional relevant data that could have further informed our assessments of the available evidence. However, we think that the impact of this limitation is likely to be small, as suggested by a recent meta-epidemiologic study [74]. Second, the heterogeneity of the reporting of outcome data made meta-analysis not feasible. Third, the heterogeneity in outcomes and the large number of strategies used across studies precluded us to determine the unique influence of each strategy on a given outcome.

Our results in the context of previous research

An important finding of our review is that most of the included studies showed that the interventions were effective in improving compliance to CPGs. This is in line with findings from previous, non-condition-specific reviews, which concluded that guideline dissemination and implementation strategies are likely to be efficient [75, 76].

A large proportion of the studies included in our review examined the impact of Computerized Decision Support Systems (CDSS). Previous systematic reviews observed that CDSS significantly improve clinical practice [77, 78]. In our review, the evidence about CDSS was only available from observational, uncontrolled studies, and was restricted to two tools in France and Italy in the hospital setting. New studies evaluating other CDSS, and in other settings and countries, are therefore needed.

There is substantial evidence from non-condition specific research that audit and feedback interventions can effectively improve quality of care [79]. A recent systematic review [80] examining the effectiveness of cancer (all types) guideline implementation strategies showed that providing feedback on CPG compliance was associated with positive significant changes in patient outcomes. More research is needed about the impact of audit and feedback interventions on the compliance with breast cancer CPGs.

Educational interventions targeted to providers (both in isolation and in combination with other interventions) have shown to improve outcomes in patients with cancer [80]. Despite the low certainty obtained, the studies in our review consistently showed that educational and multifaceted interventions improve compliance with breast cancer CPGs, supporting also results from previous non-condition specific reviews [16, 81], as well as current recommendations from the Institute of Medicine [82].

In line with our finding concerning electronic reminder interventions, a Cochrane systematic review concluded that computer‐generated reminders to healthcare professionals probably improves compliance with preventive guidelines [83].

Implications for practice and research

In terms of implications for practice, given that compliance with breast cancer guidelines is associated with better survival outcomes [25], and that there are still a substantial proportion of breast cancer patients not receiving clinical guidelines recommended care [21], it is important that the most effective interventions available are implemented to improve breast cancer guideline uptake by healthcare providers.

In terms of implications for research, as in a previous non-condition-specific review [76], we observed that there is very limited data on the costs of implementing the interventions to support compliance with breast cancer CPGs, as well as a scarcity of studies evaluating the effectiveness of interventions targeting the organization of care (e.g., benchmarking tools). Research in these two areas is urgently needed to allow evidence-based decisions concerning which interventions should be rolled out and implemented widely as part of existing quality improvement programs. Also worth noting is that, up to now, the great majority of the research on this (breast cancer) area has focused on measuring the impact of the interventions on process measures (mostly compliance rates). No study measured the impact on patient outcomes, and only a small minority examined the impact on determinants of compliance behavior (e.g., providers’ knowledge, attitudes, or self-efficacy). Future research would benefit from including a broader range of outcomes (including proximal and distal), as this would help to better measure and understand the extent to which the interventions produce the intended benefits.

Future research is also needed to identify the most effective types of interventions in improving CPGs uptake, as well as the “active ingredients” of multifaceted interventions [84]. The characteristics of the CPGs intended users, and the context in which the clinical practice occurs are likely to be as important as guideline attributes for promoting adoption of CPG recommendations. Therefore, future research should focus on gaining a deeper understanding about how, when, for whom, and under which circumstances the interventions identified can effectively support guideline adherence. Using a realist evaluation methodology [85] may prove a valuable strategy in this endeavor. However, as observed in our review, the detailed characteristics of the interventions are very frequently scarcely reported. To allow progress in this area, it is of utmost importance that intervention developers and researchers offer in their published reports a comprehensive characterization of their interventions. The Template for Intervention Description and Replication (TIDieR) guidelines [86] were specifically designed for this purpose.

Conclusion

Promoting the uptake and use of CPGs at the point of care, represents a final translation step, from scientific findings into practice. In this review we identified a wide range of interventions to support adherence of healthcare professionals to breast cancer CPGs. Most of them are based on computerized decision support systems, provision of education, and audit and feedback, which are delivered either in isolation or in combination with other co-interventions. The certainty of evidence is low for educational interventions. The evidence is moderate for automatic reminder systems, and low for multifaceted interventions. For the rest of the interventions identified, the evidence is uncertain. Future research is very much needed to strengthen the available evidence base, concerning not only their impact on compliance, but also on patient important outcomes, and on their cost-effectiveness.