Dissemination of Surgical Clinical Practice Guidelines – Evaluating SAGES’ Strategies for Distribution

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Authors

Elisa Calabrese^1,2,3,6, Bethany J. Slater⁴, Wendy Babidge ^2,3 Patricia Sylla⁵, Guy Maddern^2,3

ABSTRACT

Background: The Society of Gastrointestinal and Endoscopic Surgeons (SAGES) has been a leader in the development of surgical clinical practice guidelines; however, the dissemination and implementation of these remains a challenge. We aim to analyze the user interaction with the SAGES website (sages.org) guidelines’ page and guideline downloads from their associated journal Surgical Endoscopy to help inform the organization about its distribution and dissemination methods.

Methods: Google Analytics from the sages.org website and Surgical Endoscopy downloads for each guideline were obtained from July 2023 to April 2024, as well as number of downloads for the lifetime of the guideline. Data was organized by overall guideline popularity, defined as number of sages.org views or number of journal downloads, and its associated citations. Popularity by country was only informed by Google Analytics data from sages.org. The country’s associated economic status – high, upper middle, lower middle, and low-income was obtained and a chi-squared test, applied to proportions, was performed on each guideline to determine if the economic status of the country significantly influences guideline popularity (p-value less than 0.05, confidence interval 95%).

Results: The hiatal hernia guideline had the most sages.org views and citations over the 9-month period; however, the management of diverticulitis guideline had the most journal downloads from time of publication. Colorectal surgery (CRS) guidelines were the most popular category in journal downloads which was not observed in sages.org views. Additionally, the popularity significantly differed in four guidelines based on the country’s economic status.

Conclusions: Society websites and journals were found to be reasonable platforms for dissemination of guidelines, with viewership and downloads numbers in the tens of thousands for some articles. Guideline age did not play a role in popularity via either platform. The variability in engagement across platforms may suggest different audiences with different needs. The data emphasizes the importance of SAGES diversifying their platforms for broader dissemination.

Keywords: Clinical practice guidelines · Surgery · Recommendations · Guidelines · Distribution · Dissemination · Quality improvement

INTRODUCTION

Clinical practice guidelines (CPGs) are intended to provide evidence-based recommendations for patients and clinicians. They can also provide insight into resource distribution, support policy change, and promote future research efforts [1]. Thousands of guidelines have been published to date, however their impact in the healthcare system is not always appreciated and instituted into practice. On average, it takes 17 years for research evidence to change clinical practice [2]. In addition, newer technological innovations can take between four to six years to achieve 25 citations in the medical literature [3]. CPGs experience a similar delay in changing health care practices and this is an issue as evidence in guidelines is often superseded with new available evidence within 3-5 years [4,5].  Prompt integration into clinical practice is encouraged to ensure the most current data is being used in guiding patient care.

Dissemination and implementation (D&I) science is the study of different theories, models and frameworks to promote the adoption and integration of evidence-based recommendations into routine clinical practice to improve overall health care [6, 7]. D&I science is a critical part of the CPG lifecycle and helps close the gap between recommendation and practice. Successful introduction of CPGs into clinical practice requires a multi-phasic approach, including dissemination, adoption, implementation, and sustainability. Each phase is essential, and typically requires different strategies for success [8]. These steps in a guideline’s lifecycle also promote additional data collection on clinical outcomes and cost savings to ensure each new intervention is pragmatic to clinical stakeholders. Studies have demonstrated that CPG adherence improves clinical outcomes but more data would motivate increased funding and resources towards guideline development and implementation [9]. As CPG development is a resource-intensive process, it is important to break down each step of the process to understand how resources can be better allocated to make it as efficient as possible with the ultimate measurement of “success” being improved clinical outcomes, cost savings, and minimization of health inequities.

Despite several decades of evidence-based CPG development, implementation remains a challenge. Common barriers relate to contextual relevance of CPGs, local and environmental  resources, personal and organizational engagement and capacity for change [10]. Variability in provider awareness and training, lack of incentives and systemic barriers also contribute to low adoption. Lastly, the lack of a centralized body to arbitrate between competing CPGs that may differ in quality and recommendations, also poses challenges to implementation. There is also the notion of “if it’s not broken, don’t fix it” and if two interventions result in similar outcomes for patients, then dismantling the current system may seem moot. As the name suggests, guidelines guide clinician decision making, however, measuring the direct value of CPGs is difficult because clinical decision-making is complex and multifactorial [11, 12]. For this reason, isolating the role of CPGs in this process needs to be explicit. Another complexity is the varying strategies, facilitators, and barriers to CPG implementation and the absence of data on what is most effective, making it difficult to standardize the process[10, 13–17]. It often falls on the end-user, including the clinician, to stay updated and implement CPGs into their practice. However, it is important for professional societies that develop guidelines to also develop strategies to facilitate and support  implementation of CPGs in clinical practice[13].

Dissemination is the first and rate-limiting step in the implementation of CPGs. In an Australian national survey of 286 general practitioners regarding nine different CPGs with varying dissemination strategies,  6-48% of physicians were unaware of some of the newer guidelines, and only 7% agreed that they were a convenient source of advice [18]. This insight demonstrates the need for reliable dissemination of guidelines as there is substantial variability in strategies used and their associated reach.

The Society of Gastrointestinal and Endoscopic Surgeons (SAGES) is an organization with over 7,500 members worldwide, with a mission to innovate, educate, and collaborate to improve patient care. It has especially been instrumental in educating and training surgeons in minimally invasive surgery. As of June 2024, among 7,298 SAGES members, 56% were currently practicing surgeons in the U.S. and Canada and 14% were currently practicing surgeons outside of the U.S. and Canada. The remaining 30% of members were comprised of retired surgeons, trainees, physician assistants, nurses and other health affiliates. Less than 0.0005% were non-surgeon practitioners (e.g. internal medicine).  In line with its mission, SAGES has been a global leader in the development of surgical CPGs with a dedicated committee within the organization for their creation and protocols in place to ensure robust methodology [19, 20]. SAGES guidelines are published in its peer-reviewed journal Surgical Endoscopy, and distributed via an emailed bulletin board, social media, and on a guideline-specific webpage. The effectiveness of SAGES CPGs dissemination strategies has not been formally evaluated. This study aims to investigate the impact of the SAGES CPGs following dissemination by analyzing user engagement across the platforms where CPGs are distributed.

METHODS

The SAGES guidelines website, “SAGES Clinical/Practice/ Training Guidelines, Statements, and Standards of Practice”, houses all their published CPGs and their associated visual abstracts under the “Publications” tab off their main page. [21] The individual guidelines are listed under relevant categories which include achalasia, colorectal surgery (CRS), education/training, endoscopy, gastroesophageal reflux disease (GERD), hernia, hepatobiliary (HPB)/solid organ, metabolic/bariatric, and minimally invasive surgery (MIS). The CPGs are available to the public, including non-SAGES members. Google Analytics traffic data on the SAGES guidelines website (abbreviated here as ‘sages.org’) was obtained retrospectively for all published guidelines from July 2023 to April 2024 by the information technology personnel (J.L.) in the organization [21]. Traffic data on sages.org prior to July 2023 could not be obtained given that Google Analytics changed their analytics methods and did not back import earlier data. The data retrieved over the 9-month period included page path, country, number of total views, number of total users, views per user, average engagement time, and event count (Table 1). Page paths linked to miscellaneous, policy, position papers, position statements, privileging and credentialing were excluded. Other exclusions included duplicates, page paths associated with systematic reviews or clinical spotlight reviews, and page paths not associated with a guideline. The number of citations for each guideline was also recorded in November 2024 using Google Scholar. SAGES distributes guidelines on X (formerly Twitter) as well, however, the data on its reach was unattainable by IT despite several attempts.

Table 1. Description of metrics received from google analytics, their amateur definitions, and their limitations

SAGES CPGs are published in Surgical Endoscopy, the official SAGES journal. Guideline publications are generally open access, meaning they are accessible to the public. The journal’s Publisher (M.B.) provided data regarding downloads for each SAGES guideline from July 2023 to April 2024, to be directly comparable to the sages.org views. In addition, journal downloads for the lifetime of each guideline were obtained from the time of publication through September 2024. These data were made available in a Word Document with number of guideline downloads provided by month requested and total for the lifetime of each guideline.

The aims in  organizing this data were to determine:

1. guideline popularity as measured by number of views on sages.org over a 9-month period (overall and by country), and by number of downloads from Surgical Endoscopy over a 9-month period in addition the lifetime of the guideline
2. guideline category popularity as measured by total number of views in each category on sages.org over a 9-month period and Surgical Endoscopy downloads in each category over a 9-month period in addition to the lifetime of the guideline
3. if the economic status of a country influences guideline popularity (measured by sages.org views over a 9-month period)

The SAGES guidelines website is free and accessible to the public. Surgical Endoscopy, however, uses a hybrid publishing model meaning that if the author pays for it the article can be open access to all users, otherwise a subscription model must be in place for the user to access it.  All SAGES members can access all articles from Surgical Endoscopy once they login to the SAGES website and then continue on to the journal.

Sages.org and Surgical Endoscopy data

Data was organized using Microsoft Excel first by guideline type, and then by category (achalasia, CRS, education/training, endoscopy, GERD, hernia, HPB, and MIS) [21, 22]. Number of views and downloads per guideline and number of views and downloads per category were calculated by summing the relevant cells in excel. Views per category were then normalized by the number of guidelines in each category to ensure a fair comparison across them.

Sages.org data only

The data was also organized by country and ranked based on number of views on sages.org. Once the sum of the total number of views for each country was determined, it was divided by its population and multiplied by 100,000 to determine views-per-capita.

The economic status of each country was recorded as high-, upper middle-, lower middle-, or low-income as determined from the World Bank website [23]. The top ten countries based on number of views-per-capita for each economic status were then determined and the top five guidelines based on views were recorded for each of these countries. The popularity of each guideline based on the economic status of the country was then calculated. A Chi-squared test for the comparison of two independent proportions, expressed as a percentage, was then calculated for each guideline to determine which guidelines had a statistically significant difference between one economic category to another (Table 2) [24]. Statistical significance was defined as a p-value less than 0.05, 95% confidence interval.

Table 2. Number of times guideline was found within the top five for views in the top ten countries by category of economic status.

HIC represents high-income country. UMIC represents upper middle-income country. LMIC represents lower middle-income country, LIC represents low-income country.
*** = statistically significant trend in data (p-value less than 0.05)

RESULTS

A total of 27 guidelines from the SAGES’ website were evaluated after exclusions were applied. The median number of sages.org views across all guidelines over the 9-month period was 2,719 with an interquartile range (IQR) of 7,431 (1,074-8,505). The median number of downloads over the 9-month period was 174 with an IQR of 647 (32-679) and over the lifetime of the guideline was 1,486 with an IQR of 2,753 (969-3,722) (Table 3).

The “Hiatal hernia” guideline (ID 1) had the most sages.org views over the 9-month period at approximately 39,000. The “Management of diverticulitis” guideline (ID 23) was the most downloaded guideline from Surgical Endoscopy with 31,135 lifetime downloads. This was followed by the “Enhanced recovery in colon and rectal surgery guideline” (ID 17) at 8,750 lifetime downloads and the “Hiatal hernia” guideline (ID 1) with 8,420 lifetime downloads. A complete list of the number of sages.org views, citations and downloads per guideline is included in Table 3.

Table 3. Guideline name, category on sages.org, year published, sages.org views per guideline, citations per guideline, and Surgical Endoscopy downloads.

Listed from highest to lowest number of sages.org views.

Figure 1 represents sages.org views versus journal downloads for each guideline. While there is considerable overlap in popularity, the “Management of diverticulitis” guideline (ID 23) and the “Enhanced recovery in colon and rectal surgery” (ID 17) have been far more commonly downloaded from the journal than viewed on the sages.org website. When comparing the year of publication of a guideline with the number of views on sages.org over the 9-month period and with the 9-month period and lifetime downloads, there is no correlation between the age of the guideline and popularity (Fig. 2). Guideline citations since publication (lifetime) represented a combination of the top ten most popular guidelines on sages.org and in journal downloads. The top three guidelines for number of lifetime citations were “Hiatal hernia” (ID 1), “Laparoscopic biliary tract surgery” (ID 4) and “Safe cholecystectomy” (ID 5).

Fig. 1. Number of views on sages.org (9-month period) and downloads (9-month period and lifetime) per guideline. X-axis is the associated ID of the guideline based on Table 3.

Fig. 2. Number of views on sages.org (9-month period) and downloads (9-month period and lifetime) per guideline by year of publication.

MIS, Hernia, HPB, GERD and Achalasia were the categories with the most sages.org views, ranked from highest to lowest. After normalizing for the number of guidelines in each category the ranking changed to Hernia, GERD, MIS, HPB and Achalasia from highest to lowest. These five categories comprised 95% of all guideline views on sages.org despite only comprising 56% of the categories. Lifetime journal downloads for guidelines demonstrated a different trend with CRS, Hernia, GERD, HPB, and Achalasia comprising the top five categories downloaded from high to low. MIS therefore appears to be more popular for sages.org users and CRS more popular amongst journal downloads when comparing over the same 9-month period (Fig. 3).

Fig. 3. Views and downloads per category after being  normalized by the number of guidelines in each category

A list of the top 10 countries in sages.org views per capita over the 9-month period for guidelines is included in Figure 4. Barbados has a lower population by order(s) of magnitude relative to the other countries on this list. The United States was ranked second in number of views-per-capita behind Barbados (Fig. 4). The distribution of the data was found to be positively skewed with a median of 1.9 views-per-capita, interquartile range of 4.1 (0.64–4.68) (Fig. 5).

Fig. 4. Views per capita by country – top 10 countries.

Fig. 5. Distribution of views-per-capita data.

Of the top 10 for sages.org views per capita (Fig. 3), 90% were from high-income countries. The “Hiatal hernia” (ID 1) and “Laparoscopy for surgical problems during pregnancy” (ID 2) guidelines were found to be most popular among high-income countries, and 30% lower in popularity among low-income countries, however this was not found to be statistically significant (p-value 0.06 and 0.10, respectively) [25, 26]. The “Laparoscopic ventral hernia repair” (ID 3) guideline similarly demonstrated more popularity among high-income countries, and 50% lower in popularity among low-income countries (Fig. 6, p-value 0.02)[27].

Fig. 6: Laparoscopy for ventral hernia repair guideline popularity by economic status. *p-value <0.05

Finally, the largest difference was seen in the “DVT prophylaxis in surgery” (ID 8) guideline with a difference of 80% between high- and low-income countries (Fig. 7, p-value 0.0005) [32].

Fig. 7: DVT prophylaxis in surgery guideline popularity by economic status. *p-value <0.05

In addition, sages.org views were found to be significantly different between middle-income and low-income countries in the “Laparoscopic biliary tract surgery” (ID 4) guideline (Fig. 8, p-value 0.0223)[28].

Laparoscopic biliary tract surgery guideline

Fig. 8: Laparoscopic biliary tract surgery guideline popularity by economic status. *p-value <0.05

Conversely, the “Surgical treatment for GERD” (ID 6) guideline was found to have significantly greater popularity in low-income countries compared to high-income countries (Fig. 9, p-value 0.0285) [30].

Fig. 9: Surgical treatment for GERD. *p-value <0.05.

DISCUSSION

SAGES is a leader in surgical CPG development and dedicates significant resources towards the development of rigorous guidelines. Understanding the effectiveness of its dissemination strategies is an important first step towards implementation of best practices worldwide. The two main dissemination platforms for SAGES guidelines – sages.org website views and Surgical Endoscopy downloads, were evaluated with respect to guideline popularity and access based on geographic location.

The top three guidelines based on the number of sages.org views were “hiatal hernia”, “laparoscopy for surgical problems during pregnancy” and “laparoscopic ventral hernia repair”, with hiatal hernia at nearly 40,000 views over a nine-month period. This differed from journal downloads, where the top guidelines were “management of diverticulitis”, “enhanced recovery in colon and rectal surgery” and “hiatal hernia”. The age of any given guideline was not found to correlate with its popularity and although the number of citations did not directly correlate with either sages.org views nor journal downloads, there was generally concordance between popularity on either of the platforms and number of citations.

The most popular guidelines based on sages.org views over the 9 months period were in Hernia, GERD MIS, HPB, and Achalasia, whereas CRS, Hernia, GERD, HPB, and Achalasia-related guidelines were the most popular 9-month and lifetime Surgical Endoscopy downloads. Differences in guideline popularity across these platforms may reflect differences in access. While access to SAGES guidelines on sages.org is free to members and non-members alike, access to Surgical Endoscopy requires a subscription, unless authors cover the journal fees to make the article open access. Non-SAGES members including surgeons from LMIC, patients, non-surgeon physicians, administrators and other stakeholders may preferentially download guidelines from the SAGES website which is free to the public. These differences could also suggest that readers with specific specialty interests such as colorectal surgeons, are directed to Surgical Endoscopy through society websites, newsletters, social media platforms, or search engine results.

Based on the sages.org data, there was substantial geographic variability in guideline distribution, reaching 176 different countries. Barbados was among the top 10 countries in terms of views-per-capita; however, it is likely an outlier, due to its relatively low population. Most (99%) countries in the top 20 were found to be high-income countries. This finding led to further investigation as to whether specific guidelines were more popular based on the economic status of the country. The “laparoscopic ventral hernia repair” and “DVT prophylaxis in surgery” guidelines were significantly more popular in high-income countries while the guideline on “laparoscopic biliary tract surgery” was significantly more popular in middle-income countries. Interestingly, the guideline on “surgical management for the treatment of GERD” was significantly more popular in low-income countries. These trends may reflect differences in educational needs across countries based on available resources and represents one of the known challenges to implementation of guidelines—contextual relevance.

In addition to publishing guidelines in Surgical Endoscopy and sages.org, SAGES also disseminates guidelines at annual meetings, through webinars, resident educational and training courses, and through social media. The lack of data on traffic generated by social media posts of SAGES guidelines -including views, posts, reposts and access to sages.org vs Surgical Endoscopy links across various platforms including X, Facebook, LinkedIn and Doximity, represents a major limitation of this study. This information would not only help the organization identify the most effective platforms for reaching a wider audience but also allow for a more targeted and strategic approach to optimize guideline dissemination. Other limitations include the narrow time frame available to analyze guideline viewership on sages.org views, which limited a more in-depth assessment of user engagement overtime and relative to other platforms. The sages.org views can only be reasonably compared directly to the 9-month Surgical Endoscopy downloads and not to lifetime downloads. Furthermore, locations from the sages.org website were by country, therefore broad, and due to technology like virtual private network (VPN), must be heavily scrutinized before being acted upon. Finally, it would be useful to know who is accessing guidelines—academics, surgeons, other providers, patients and what platforms are preferred by each to allow for a more targeted approach to dissemination. Overall, this data provides a glance at the dissemination methods of surgical guidelines by SAGES, but longer time frames and social media platform data would provide a deeper insight for future investigations.

CONCLUSION

SAGES is a leader in surgical CPG development and is committed to lead effective distribution and dissemination of its guidelines. Two of their dissemination methods – its website, sages.org and its associated journal, Surgical Endoscopy demonstrate different user engagement with respect to guideline popularity, emphasizing the importance of varied platforms. Future research to understand audience background, traffic patterns and the role of other platforms, namely social media, on dissemination of SAGES guideline popularity will be helpful to understand targeted approach to effective dissemination.

 Acknowledgements

Acknowledgement to the SAGES organization, Jason Levine from IT, and Springer Publisher.

Funding

The guidelines fellow is funded by a SAGES Education and Research Foundation (SERP) Grant.

Disclosures

Dr. Elisa Calabrese is a research fellow whose salary is supported by SAGES. Dr. Bethany Slater is the Chair of the Guidelines Committee for Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and a consultant for Cook Medical and Hologic. Dr. Patricia Sylla is a consultant for Activ Surgical, Stryker, Ethicon, Safeheal and Exero. Dr. Guy Maddern is the Surgical Director of Research, Audit and Academic Surgery of the Royal Australasian College of Surgeons. Dr. Wendy Babidge has no conflict of interest or financial ties to disclosures.

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Author Affiliations:

Elisa Calabrese^1,2,3,6, Bethany J. Slater⁴, Wendy Babidge ^2,3 Patricia Sylla⁵, Guy Maddern^2,3

1. Department of Surgery, University of California San Francisco-East Bay, Oakland, CA, USA
2. School of Medicine, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, Australia
3. Research, Audit & Academic Surgery, Royal Australasian College of Surgeons, Adelaide, Australia
4. Department of Surgery, University of Chicago, Chicago, IL, USA
5. Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
6. 1411 E 31st St, Oakland, CA 94602, USA

Corresponding author: Elisa C. Calabrese