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* From the Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina.
Correspondence to: John E. Heffner, MD, FCOP, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 812, PO Box 250623, Charleston, SC 29425; e-mail: heffnerj{at}musc.edu
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Introduction |
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During the ensuing years, the quality and cost of health care have become major concerns of the medical profession, the public, third-party payers, and multiple local, state, and federal regulatory agencies. These concerns have spawned health services research studies that have demonstrated shortcomings in our health care system, including regional variations in medical practices,1 inappropriate use of medical interventions,2 and early adoption of new technologies before effectiveness has been established.3
There has been no shortage of attempted solutions to these problems. Physicians have experienced peer review organizations, mandatory continuing medical education requirements, professional board recertification, and treatment preauthoraization, to name a few. Although these interventions have varied in effectiveness and rationality of design, they hold in common the recognition that physician decisions not only influence the health of their patients but also determine the cost of their care. It follows that the ability to influence physicians’ practices could improve the quality of care while controlling health care expenditures.4 Managed care represents the institutionalization of strategies to establish influenced care.
Faced with political and economic influences to control costs and alter their practices, physicians have become increasingly challenged to maintain professional standards of care and to shape this new health care environment for the benefit of their patients and their profession. The explosion of medical knowledge has not simplified this challenge. It has been estimated that more than 33,000 citations are added to MEDLINE each month. In an era of greater scrutiny and accountability, the ability of physicians to update their medical knowledge and to place newly acquired information in context with existing knowledge to improve clinical practice has been sorely stressed.5
This is the health care environment in which the American College of Chest Physicians (ACCP) began to develop and promote clinical practice guidelines (CPGs) more than 15 years ago. Practice guidelines represent the interests of professional societies to identify best current practices of care, to educate physicians, and to improve health care delivery. The premise of CPGs lies in evidence-based medicine, which is ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.‘6 Guidelines themselves have been defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.‘7
In operational terms, CPGs discourage ineffective medical practices and encourage effective care in order to improve health outcomes.8 9 10 11 12 13 In strategic terms, guidelines provide the necessary evidence-based data to empower clinicians to make informed decisions and to counter managerial influences to alter their practices in ways that may not be in the best interests of their patients. Although guidelines have been identified as having lineage in traditional medical writings,11 they have a uniqueness all their own in presenting coherently sequenced recommendations that link specific information sources with specific information uses.14
What CPGs do not represent is cookbook medicine. Clinical guidelines summarize recent knowledge in a manner that encourages flexible application of recommendations to the unique clinical problems of individual patients. Guidelines are the substrate for experienced clinicians who interpret science with an intention to practice the art of medicine for the benefit of the individual patients.
Despite more than a decade of productive guideline development, however, the ACCP has reason to pause and reflect on the value of commissioning new guidelines in the future. Although guidelines are written with the purpose of hastening the incorporation of research findings into routine practice and of supplementing rather than replacing clinical judgment,15 physicians remain wary of their intent. A 1994 survey of American College of Physicians members indicated that 43% of those surveyed believed that guidelines would increase health care costs, 68% believed that CPGs would be used to discipline physicians, and 34% believed they would make medical practice less satisfying.16
Combined with the reluctance of physicians to adopt guidelines is the tremendous proliferation of guideline publications, defying the ability of clinicians to have knowledge of a relevant guideline’s existence, let alone an understanding of its content. In some medical fields, multiple overlapping, conflicting, and poorly constructed guidelines17 threaten physicians with a Tower of Babel of practice recommendations.18
The effectiveness of CPGs have also been called into question. Studies that failed to detect any impact of CPGs on clinical practices or health outcomes19 20 21 have created a sense of suspicion that CPGs lack the very foundation in validity that guidelines themselves demand for the clinical care they recommend. Only recently have rigorous investigations demonstrated efficacy of guidelines in altering clinical practice.22 23 Although the weight of the evidence has found that guidelines do improve the process and the outcome of patient care, the size of the improvements has varied and may not have been lasting.24 It is understandable that some professional societies have begun to inventory the effectiveness of their CPGs, considering the high costs of their production.25
So, where does the ACCP stand regarding CPGs for the next decade? It appears to the College that the goals of guidelines, to influence and empower physicians toward improved health care, are worth maintaining. It also appears that guidelines contribute to improved processes and outcomes but by themselves are not sufficient to make the sweeping changes that our profession and the public expect. The ACCP recognizes that, for guidelines to achieve their goals, strategies for implementing CPGs are as important as the methodologies for their development. The next era of CPGs will continue the effort to develop guidelines that are simple, pragmatic, usable, and flexible,26 27 but they will increasingly focus on strategies to promote implementation.
With new strategies for guideline implementation, we must understand that very little theory, practical experience, or research evidence exist to help us formulate an ideal approach for enhancing the ability of CPGs to alter physician behavior.28 Available tools for guideline implementation include computer systems,29 30 academic detailing,31 recruitment of local medical opinion leaders,32 performance measures,33 educational outreach, and continuing medical education.34 Considering the diversity of these tools, effective guideline implementation requires their integrated application in a manner that effectively communicates best practices. As such, efforts to implement guidelines will eventually transcend guideline implementation and form general strategies for promoting the ongoing education of practicing physicians.
This last thought is the starting point for the ACCP conference on ‘Translating Guidelines into Practice,‘ reported in this supplement. Experts in diverse fields that include guideline development, adult learning theory, and physician education convened with College leadership to discuss guideline implementation. Plenary presentations formed the foundation for breakout sessions that reflected on the College’s theories for CME, conference design, and publications as they pertain to guideline implementation. The reports from these breakout sessions are included in this supplement and will be used by College leadership to integrate ACCP efforts in physician education, guideline development, and dissemination.
We believe that this conference will assist the ACCP in creating a coherent strategy for guideline implementation that will assist clinicians in their efforts to incorporate best evidence into clinical practice. We congratulate the College for its commitment to supporting the guideline movement, which is worth preserving. The American health-care system has been described as a ‘non-system‘ defined during this last decade by ‘cost and chaos.‘35 Because CPGs are concerned with the quality and value of health care rather than just with examining its costs, they can assist us in keeping an eye on our profession’s bottom-line issues, which are quality health care and improved patient outcomes.
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This article has been cited by other articles:
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  M. J. McQueen Overview of Evidence-based Medicine: Challenges for Evidence-based Laboratory Medicine Clin. Chem., August 1, 2001; 47(8): 1536 - 1546. [Abstract] [Full Text] [PDF]
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 K. M. Frankel Clinical Guidelines vs Clinical Practice Chest, February 1, 2001; 119(2): 667 - 667. [Full Text] [PDF]
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