A population-level evaluation of barriers and facilitators to referral in Cytoreduction/Hyperthermic Intraperitoneal Chemotherapy using knowledge translation methodology.

Abstract

Introduction: Referral for CS/HIPEC is variable, and barriers encountered by referring physicians are unknown. Identification of such barriers is useful for the creation of tailored knowledge translation (KT) strategies. Methods: Interviews of 20 medical oncologists and surgeons in the New York (NY) area were completed to identify barrier topics, using the Pathman framework of uptake of innovations (awareness, agreement, adoption, adherence) at the various levels of the individual, practice group, and organization. Barriers were used to structure a survey for evaluation of prevalence at the population level of medical oncologists and surgeons in NY State. Results: Barrier topics of awareness included training at a CS/HIPEC center, and availability of multidisciplinary cancer conferences. Agreement barriers centered mainly on quality of published literature, and the paradigm shift of carcinomatosis as a systemic to locoregional disease process. Adoption barriers included knowledge of outcomes of a CS/HIPEC surgeon, and concerns with morbidity/mortality rates. Adherence barriers included the lack of reflection of CS/HIPEC in current CPGs, financial/resource and logistic concerns of referrals, and lack of quality measures for the procedure. For the survey, 119 responded (12% response rate), including 42 medical oncologist and 77 surgeons. The majority were aware of CS/HIPEC (n=113, 95%). Medical oncologists were less likely than surgeons to agree with CS/HIPEC related to published evidence (76% vs 92 %, p = 0.02). Surgeons were more likely to be aware of where to refer patients for the procedure, and were less likely to have concerns regarding morbidity/mortality, compared with medical oncologists (p = 0.05, p = 0.04). Representation of CS/HIPEC in CPGs and quality measures/outcomes data was felt to result in adherence to a regular referral practice. Discussion: This prospective study of stakeholders for CS/HIPEC is the first to evaluate and characterize barriers to referral for this complex and controversial surgical innovation, with prevalence at the population level.