Aims:
Clinical guidelines and care pathways aim to improve healthcare quality, safety, and consistency; however, adherence remains variable. In cancer care, where pathways are complex and multidisciplinary, the absence of consistent approaches to measuring adherence limits the ability to evaluate implementation, benchmark performance, compare findings, and inform policy and quality improvement. This systematic review synthesised international approaches used to measure adherence to clinical guidelines and care pathways and identify methodological gaps relevant to cancer care.
Methods:
Four databases were searched from inception to March 2026. Eligible studies were primary research describing the development, implementation, or evaluation of tools, indicators, frameworks, or models for measuring adherence to clinical guidelines or care pathways. Studies focused solely on patient adherence, patient-reported outcomes, or minimum datasets were excluded. Data were narratively synthesised and analysed inductively across five measurement stages: identifying, selecting, categorising, quantifying, and evaluating adherence attributes.
Results:
Sixty-three studies were included. The evidence base was concentrated in high-income countries, most notably the Netherlands (25%, n=16). Most developed adherence indicators (56%, n=35) or measurement tools (40%, n=25), with few describing broader conceptual frameworks or models. Only 11% of studies used systematic methods to identify adherence attributes, while 48% used Delphi methods to support indicator selection. Approaches to categorising adherence attributes varied substantially, reflecting inconsistent definitions and constructs. Forty percent of studies reported an aggregated adherence measure, with limited evidence of validation or assessment of measurement reliability. Overall, adherence measurement approaches were predominantly process-focused and lacked theoretical foundations or standardised reporting.
Conclusions:
Current approaches to measuring adherence to clinical guidelines and care pathways are methodologically diverse and poorly standardised, limiting their use for assessing quality and equity in healthcare delivery. Development of theory-informed, pragmatic, and psychometrically robust measurement frameworks are needed to support meaningful evaluation of complex multidisciplinary care pathways, including cancer care.