Guidelines for urological care inform most of our day-to-day care delivery needs. From prostate cancer, lower urinary tract symptoms, and incontinence to urolithiasis, priapism, infertility, and overactive bladder, both the AUA¹ and EAU (European Association of Urology)² put forth evidence- and expert opinion–based recommendations as leading international organizations (Table 1).

Table 1. International Urology Guidelines

Guidelines are serially updated providing up-to-date support for clinicians and increasingly engage patients as key stakeholders in guideline development. For example, the EAU Guidelines Patient Representative Handbook provides distinct roles and responsibilities for patient representatives. Patient guidelines and educational resources are also increasing as in the National Comprehensive Cancer Network Patient Guidelines across cancer types and Urology Care Foundation website resources to supplement guideline-recommended care. These rich resources can help support self-efficacy and patient activation, and inform decision-making to align with patient preferences.

When it comes to monitoring and improving adherence to urology guidelines, audit and feedback is a common implementation strategy centered on measuring performance and providing clinicians and systems feedback on that performance with the intention of improving outcomes. While there are best practices for such feedback (Table 2),³ it remains unclear how well we are incorporating these approaches to optimize feedback and improve guideline adherence.

Table 2. Fifteen Suggestions for Designers of Practice Feedback and Example Implementation Strategies

Nonetheless, understanding how well or not we are doing as clinicians, practices, or even as a national or global urological community adhering to guideline recommendations rests upon measurement. We need clear, accessible common measures aligned with guideline recommendations, ie, audits, across urological diseases, especially when it comes to strong recommendations. For example, are we giving single instillations after transurethral resection of bladder tumor in eligible patients? Are we giving too much androgen deprivation monotherapy for localized prostate cancer? Or are we fully evaluating all gross hematuria patients?

It is no surprise that clinicians may not follow guideline recommendations due to lack of awareness, agreement, clinical inertia, or even external barriers.⁴ Like others, our groups have tried to figure out why we may not be adhering to guidelines. For androgen deprivation monotherapy in localized prostate cancer, we found most providers actually avoided this practice (see below about “minding the gap”), though they may be more likely to give androgen deprivation therapy in selected cases of elderly patients or due to patient preference exerting social influences on the provider.⁵ For postoperative intravesical therapy, practice varies widely–in some locations almost no eligible patients receive it, while in others many do.⁶ Barriers include late ordering, local storage problems, lack of training, skills, and workload affecting motivation for adherence.⁷ Facilitators include incorporating reminders in transurethral resection of bladder tumor pro forma and national performance targets.⁸

When we have the audits covered, and we understand the barriers to guideline adherence, then we can strategically implement feedback that follows best practices–eg, action-oriented, timely, and under control of the individual–and addresses clinicians and settings with the greatest gaps between observed and expected performance. Importantly, failing to “mind the gap” and focus on the largest gaps in guideline adherence, ie, most opportunity for improvement, may waste significant resources. Focusing on small gaps between observed and expected care could be highly inefficient as there are many clinical nuances that may drive care away from guideline recommendations. This would be similar to the Pareto principle, whereby 20% of practices or settings may be driving 80% of guideline nonadherence. Tailoring efforts to the areas with the most opportunity to improve likely makes sense rather than large investments for marginal or incremental improvement opportunities.

More broadly, we can engage in implementation science frameworks like the Knowledge-to-Action framework⁹ to guide selection and tailoring of strategies alongside audit and feedback to bridge “know-do” gaps. This framework has a “knowledge creation” funnel in the center that describes the guideline generation process with outer action-oriented steps that include auditing of guideline use (ie, knowledge) with the goal of addressing gaps in guideline-adherent care through tailored, stakeholder engaged implementation strategies. In the case of improving adherence to postoperative intravesical therapy, the RESECT (Transurethral REsection and Single Instillation Intra-vesical Chemotherapy Evaluation in Bladder Cancer Treatment) observational study contains a nested randomized controlled trial to assess whether audit and feedback plus access to reporting pro forma and educational materials improve the attainment of single instillation (among other quality indicators) and recurrence rates, over and above audit participation alone (https://clinicaltrials.gov/ct2/show/NCT05154084).

Fortunately, national and international efforts are underway to support the “audit” part of urology guideline adherence. This core component is facilitated through advancing technology for automated chart abstraction within electronic health records and realization from payers that investing in quality audits can yield disproportionate benefits for patients and costs. Indeed, MUSIC (the Michigan Urological Surgery Improvement Collaborative) and the national AQUA (AUA Quality) Registry are gaining significant momentum to efficiently measure how we are doing as urological care providers and identify opportunities for improvement. Internationally, IMAGINE (the IMpact Assessment of Guidelines Implementation and Education) and Optima (Optimal treatment for patients with solid tumors in Europe through artificial intelligence, www.optima-oncology.eu) are working to rigorously assess international practice variations in adherence to strong, evidence-based guideline recommendations, and in the case of Optima, using artificial intelligence and dynamic computer-interpretable guidelines to support clinician and patient decision-making. It is clear this is a moment in time to realize national and international audits and the potential to support wide-scale improvement in guideline adherence.¹⁰

The promise of effective feedback and support for patients and providers to improve guideline adherence is real, especially if we engage as a global urological community to do the best we can for our patients by keeping track of how we are doing. We need to have a clear understanding of what guideline adherence we are measuring and how we are going to keep track. We then need to engage in best practices for feedback and be thoughtful about our implementation strategies to support guideline adherence and improvement that is acceptable to clinicians, feasible to implement in practice, and patient-centered and equitable to meaningfully decrease the burden of urological disease.