EURURO Vol. 71 No. 4

689 692

[1_TD$DIFF]Re: Low Adherence to Guidelines in Nonmuscle-invasive
Disease
van Rhijn BWG, Burger M
Nat Rev Urol 2016;13:570–1
Experts’ summary:
The authors address the thorny issue of the lack of adherence to
Clinical Practice Guidelines highlighting high-quality evidence
based nonmuscle-invasive bladder cancer (NMIBC) guideline
recommendations from the American Urological Association/
Society of Urologic Oncology, and the European Association of
Urology as exemplars . In particular, they emphasise three
strong practice recommendations underpinned by high-quality
evidence: immediate intravesical installation of chemotherapy
in patients with presumed low-risk or intermediate-risk
NMIBC, the performance of a second transurethral resection
for high-risk NMIBC, and the administration of adjuvant intra-
vesical Bacillus Calmette–Gue´ rin immunotherapy in high-risk
NMIBC. Data from North America, Europe, and Australia are
cited illustrating variability and general lack of adherence
(ranging from 0.5% to 65%) to these recommendations.
Interestingly, they propose that if young urologists, even
from the best institutions, are not trained within environ-
ments whereby strong evidence-based practice recommen-
dations are adhered to, they are unlikely to implement such
practices as they embark on their independent careers. The
obvious risks are that patients are not receiving the best care,
care is not standardised, and patient outcomes are likely to be
compromised. The excellent parting conclusion from the
authors is that the reasons for the lack of adherence need to
be investigated in future research and additionally they
propose some strategies: (1) national adoption of interna-
tional guidelines, (2) attendance at guideline update courses,
and (3) increasing social media traffic
Experts’ comments:
This is an excellent article drawing attention to the current
and pressing issue of suboptimal guideline adherence in the
face of high-quality evidence and strong recommendations.
Discordant adherence is apparent in other urological areas
such the overuse of androgen deprivation therapy for low-
risk prostate cancers and the decreasing use of androgen
deprivation therapy with radiotherapy for intermediate- and
high-risk prostate cancer .
Now that we know there are evidence-practice gaps, we
must address them; fortunately there is a significant body of
implementation research across conditions from which we
can learn . The European Association of Urology Guide-
lines Office’s increasingly transparent and robust ways of
systematically reviewing the evidence, and linking the
quality of evidence to the strength of recommendations is
an important first step in the knowledge-to-action cycle
. Now we should turn attention to: who needs to do what,
differently? Which barriers and enablers need to be
addressed?Which intervention components could overcome
the modifiable barriers and enhance the enablers? How can
behaviour change be measured and understood ?
Addressing evidence-practice gaps depends on individ-
uals changing their clinical behaviours within complex
systems Potential barriers to adherence include a lack of
knowledge/awareness, scepticism about key recommenda-
tions or the credibility of the source, a lack of resources or
skills to perform the optimal treatments, organisational/
group commitment to a particular course of action which
may limit autonomy or sanction deviance, a lack of belief in
the beneficial consequences of the recommendations,
disincentives to performing the treatments—among many
other social, psychological, organisational, and environ-
mental factors . If we are to understand the problems
and effect desired behaviour change, a theory-informed
approach is necessary.
The urological community must all march to the same
beat adhering to strong recommendations. At least we stand
a chance of finding out sooner whether the treatment/care
being provided is right for patients or not; and if not, we
change together. With the current alternative, we can be
sure that at any one time, a significant proportion of
patients are probably receiving suboptimal care and in
some cases, harmful care.
Conflicts of interest: The authors have nothing to disclose.
References
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Steven MacLennana,* , Alberto Brigantib,
Jeremy M. Grimshawc
[2_TD$DIFF], James N’Dowa
a University of Aberdeen, Academic Urology Unit, Foresterhill, Aberdeen, UK
bVita-Salute University San Raffaele, Milan, Italy
[3_TD$DIFF]c Ottawa Hospital Research Institute, Ottawa, Canada
*Corresponding author. University of Aberdeen, Academic Urology Unit,
Health Sciences Building (2nd floor), Foresterhill,
Aberdeen AB252ZD, UK.
E-mail address: (S. MacLennan).
# 2016 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
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