From America: cookbook medicine or food for thought: practice guidelines development in the USA (original) (raw)

The Use of Clinical Guidelines to Improve Medical Practice: Main Issues in the United States

International Journal for Quality in Health Care, 1997

The use of clinical guidelines bas become a key issue in the US health care system. In contrast to European systems, where such initiatives usually are controlled by one administrative agency, in tbe US there is a pluralistic approach and many kinds of guidelines coexist, initiated by health professions, managed care organizations, state or federal agencies, hospitals, and insurers. This paper reviews the main trends, indicating that guidelines will play an increasingly prominent role: use of institution-based guidelines vs national, professional, or state-based guidelines; use of more decision-support systems made possible by computerization and changes in cost containment strategies. Combining quality of care objectives with tbe business objectives of institutions increases tbe likelihood of a wider adoption by physicians. Several issues, such as the legal implications or the conflict of objectives, Illustrate limits in the use of such standards to judge individual cases; however, most recent developments tend to reconcile individual decisions and what is known from probabilities on representative samples. By bringing such information into the decision process between physician and patient, the use of guidelines challenges the traditional asymmetry of information between professionals and patients. In a context of increasing health care costs, clinical guidelines represent a very useful tool for debating rationing issues and standard benefit packages, in order to make the system more equitable. Evaluations of tbe effectiveness of clinical guidelines on performance are contradictory, but when rigorous evaluations exist, clinical guidelines are found to be effective. The amount of improvement, however, may vary considerably.

The emergence of clinical practice guidelines

Milbank …, 2007

Clinical practice guidelines are now ubiquitous. This article describes the emergence of such guidelines in a way that differs from the two dominant explanations, one focusing on administrative cost-cutting and the other on the need to protect collective professional autonomy. Instead, this article argues that the spread of guidelines represents a new regulation of medical care resulting from a confluence of circumstances that mobilized many different groups. Although the regulation of quality has traditionally been based on the standardization of professional credentials, since the 1960s it has intensified and been supplemented by efforts to standardize the use of medical procedures. This shift is related to the spread of standardization within medicine and especially in research, public health, and large bureaucratic health care organizations.

Clinical Practice Guidelines: the More, the Better?

North American Journal of Medicine and Science, 2015

Clinical practice guidelines are supposed to be evidence based and unbiased. High quality guidelines have the potential to promote the use of effective clinical services, minimize undesirable practice variation, and reduce the use of unnecessary services. Unfortunately, most of the guidelines produced thus far are flawed and untrustworthy. High quality guidelines may still have the intrinsic limitation of being too diseasefocused rather than patient-focused, and lack applicability and validity when dealing with patients with multiple comorbidities or diseases. When applicable, clinical practice guidelines may serve as a relative guidance, rather than the absolute standard. Physicians need to be critical and vigilant when faced with a plethora of guidelines as following flawed practice guidelines may result in harm to patients. The use of clinical practice guidelines as the "standard of care" as well as for pay-for-performance based on guideline adherence is unjustified.

A view into clinical practice guidelines: who uses them, who doesn’t and possibly, why

Qualitative Research in Medicine and Healthcare, 2017

Medical professional societies each develop specific clinical practice guidelines (CPGs). Based on the best available evidence, CPGs are intended to control variability and optimize quality of care in clinical practice. Yet, healthcare providers often do not accept or adhere to guidelines, but their reasons are not fully understood. When providers opt to choose not to follow CPGs, unfavorable patient outcomes including unequal access to treatment become negative consequences. In this small qualitative study, we will explore what causes non-adherence to CPGs and what changes have been made to CPGs from when physicians completed their medical residencies to the present. We interviewed physicians from a variety of medical specialties to assess how these changes may influence guideline adherence as well as the consequences of not following them. We found that guidelines may not be followed in cases where patients have comorbidities that are not described in the guidelines or when physic...

Clinical practice guidelines: Opportunities and implications

Annals of Behavioral Medicine, 1996

Clinical practice guidelines have been defined as systematica[ly developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They are intended to improve the quality, appropriateness, and effectiveness of care. While particular guidelines may be challenged on the grounds that they are not inclusive of all effective treatment strategies or are too difficult or too expensive to implement, there is evidence that guidelines can influence clinical decision-making in ways that improve treatment outcomes and sometimes also in ways that reduce costs. Guidelines are viewed by policymakers as an important factor in rational decision-making about payment practices and other policy issues, but they can provoke controversies among providers and researchers. This article gives a broad overview of practice guidelines from a health policy perspective. Strategies for guideline development are described, with a focus on guidelines developed by the Agency for Health Care Policy and Research, the U.S. Clinical Preventive Services Task Force, and managed care organizations. Issues related to implementation of guidelines are discussed, including the need to reach agreement on the standards of evidence for clinical effectiveness. Strategies are discussed for increasing the application of behavioral research findings for multicomponent treatment and population-based preventive interventions.

Contribution of Clinical Guidelines to Patient Care Practices

2020

This study was conducted to determine the knowledge and attitudes of health professionals about the contribution of clinical guidelines in patient care practices and their views on clinical guidelines and the factors affecting them. Research has a descriptive, cross-sectional research feature. The survey sample consisted of 100 health workers of Bursa Özel Medicabil Hospital. The data were collected through the questionnaire form between 1-15 February 2017. Calculations were made by giving 1 point for each correct or positive response, 0 for wrong or negative, and no answer. The descriptive statistics were assessed by t-test, one-way analysis of variance and correlation analysis in independent groups, and p <0.05 was considered significant. In the study, a positive and moderate correlation was found between healthcare professionals' knowledge of clinical guidelines and their attitudes to clinical guidelines (r = 0.35, p <0.01). Healthcare workers who were willing to take part in clinical researches were found to have higher knowledge and attitude scores related to clinical guidelines (p <0.05). As a result, opening up basic training programs and encouraging participation of health professionals in these programs in relation to clinical guidelines will play a role in increasing the quality of patient care practices carried out in our country.

The Brave New World of Medical Standards of Care

The Journal of Law, Medicine & Ethics, 2001

here have always been medical standards of care in the American health-care sector. However, never T before have they been so deeply incorporated in the delivery of health care as they are today. With the increased delivery of care through integrated delivery systems, as well as the development of the computerized patient record, medical standards of care are now used in innovative ways by providers and health plans in delivering health care to individual patients. There is great potential for even more innovative uses of medical standards of care in the future.

Implementation of Clinical Practice Guidelines in the Health Care Setting

Advances in Nursing Science, 2019

BACKGROUND Clinical Practice Guidelines Clinical practice guidelines (CPGs) are developed through a rigorous systematic methodology synthesizing the ever-increasing amounts of published literature into a practical and digestible set of clinical recommendations to be used in a healthcare setting. 1,2 The Grading of Recommendations Assessment, Development and Evaluation (GRADE) collaboration has established a widely-accepted approach for developing guidelines by rating both the quality of the evidence and the strength of the recommendation. 3 The U.S. Preventive Services Task Force (USPSTF) also develops guidelines using a similarly rigorous and transparent methodology. 4 Both approaches recognize that guidelines need to be trustworthy and understandable from the perspective of key stakeholders, and the ultimate goal is to direct clinicians in providing the most up-to-date, evidence-based, and highest quality care for their patients. Complexities in Implementing CPGs Although our literature is replete with guidelines, the expected improvements in patient outcomes and reduction in healthcare-related costs have not been realized. 1,5,6 Research suggests that on average, it takes up to 17 years for only 14% of published evidence to translate into practice. 7,8 In response to this, research has shifted to focus on how guidelines can be effectively implemented in a clinical or community setting. 9,10 These strategies are extensive and comprehensive; as one example, the Expert Panel for Recommending Change (ERIC) project, 10 names 73 strategies and their clear definitions, highlighting the breadth and combinations of possible implementation strategies. These strategies are defined as "techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice 11 " and often involve multi-faceted components.

The Need to Systematically Evaluate Clinical Practice Guidelines

Clinical practice guidelines abound. The recommendations contained in these guidelines are used not only to make decisions about the care of individual patients but also as practice standards to rate physician " quality. " Physicians' confidence in guidelines is based on the supposition that there is a rigorous, objective process for developing recommendations based on the best available evidence. Though voluntary standards for the development of guidelines exist, the process of guideline development is unregulated and the quality of many guidelines is low. In addition, the few tools available to assess the quality of guidelines are time consuming and designed for researchers, not clinicians. Few guidelines are evaluated, either before or after their dissemination , for their impact on patient outcomes. Just as with pharmaceuticals and other products that can affect patients for better or worse, perhaps it is time to develop more standardized ways to evaluate the development and dissemination of clinical practice guidelines to ensure a similar balance between risk and benefit. (J Am Board Fam Med 2016;29:644 – 648.)