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Translating Practice Guidelines Into Patient Care^*

Guidelines at the Bedside

^* From Health Services Research, Cedars-Sinai Health System, UCLA School of Medicine, Los Angeles, CA.

Correspondence to: Scott Weingarten, MD, MPH, Cedars-Sinai Health System Zynx Health, 9100 Wilshire Blvd, Suite 655, Beverly Hills, CA 90212; e-mail: weingarten{at}csmc.edu

	Abstract

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Practice guidelines have been developed by a myriad of government, subspecialty, and local organizations in an attempt to reduce undesirable variations in care and to improve the quality of care. Despite the current enthusiasm driving the creation of thousands and thousands of guidelines, their longevity will depend on the ability to demonstrate measurable improvements in patient care caused by the dissemination and implementation of guidelines. In order for guidelines to improve care, they must influence the decisions that physicians and other health-care providers make as they care for patients on a day-to-day basis. Studies on this topic show that some guideline implementation strategies are consistently effective, meaning that they lead to changes in care that benefit patients. Other strategies have been shown to be consistently ineffective. Using an evidence-based approach to selecting guideline dissemination and implementation strategies may facilitate the greatest chance of success, and enhance the probability that patient care will be meaningfully improved as a result of these efforts.

Key Words: cost of care • practice guidelines • quality of care

	Introduction

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Practice guidelines are systematically derived statements that can inform clinical decision making. Many guidelines have been developed and disseminated widely; a significant amount of resources have been devoted to this endeavor. Since guideline development, maintenance, and implementation require the allocation of significant health-care resources, much has been written about the need to document the benefits of guidelines in relation to patient care. Guidelines can be viewed as a technology in need of assessment.¹

The life cycle of a guideline begins with its development. The process by which they are created varies widely; the birth could range from a thorough review of the available scientific evidence to a swift codification of expert opinion. Many experts believe that the development process is important to ensure that the guideline most accurately reflects the available scientific evidence. Presumably, guidelines that codify the available body of knowledge have a greater chance of improving care if they are faithfully translated into clinical practice.² Although there are virtually no data derived from clinical investigations to support the belief that evidence-based guidelines will lead to greater improvements in care than guidelines developed in a less rigorous manner, experts believe that future studies will prove the value of a more rigorous development process. More research needs to be conducted to determine the benefits and costs of different approaches to guideline development.³

Although guidelines hold great promise, their ultimate value will be determined by the impact that they have on patient care,¹ including improvements in quality of care, improved patient satisfaction, and safe reductions in costs. In addition, guidelines could facilitate informed patient decision making. Over the past 10 years, there have been many studies that have evaluated the impact of guidelines on patient care. Research has demonstrated that guidelines can improve both the process and the outcome of care. In fact, 55 of 59 guideline studies demonstrated at least one beneficial change in the process of care, and 9 of 11 studies that examined patient outcomes showed improved care.³ Therefore, the preponderance of published evidence demonstrates that guidelines can improve care, although the benefits may be overestimated due to publication bias.

The probability that the guideline will change care probably relates to the implementation strategy.^{2 3 4 5 6 7} Certain guideline implementation strategies have been found to consistently improve patient care, while other strategies have been shown to result in minimal impact. An evidence-based approach could be used to select the most effective strategies that could lead to successful implementation of guidelines.²

In addition to the implementation strategy, properties of the guideline itself could affect the probability of successful implementation, although there are limited data linking guideline content or expression to eventual adoption. For example, the American Thoracic Society (ATS) sponsored the development of a guideline for the diagnosis and treatment of patients with community-acquired pneumonia.⁸ The guideline was developed by experts and used evidence to support the recommendations. However, the guideline is complicated and probably difficult for many clinicians to commit to memory (the complexity is required to reflect the clinical nuances of medicine). Without computerized clinical decision support, the probability that a clinician could utilize the ATS guidelines to assist in the care of patients with community-acquired pneumonia is probably low. At the current time, there is little rigorously derived evidence that use of the ATS community-acquired pneumonia guideline has led to widespread improvement in patient care. In this case, the guideline had a measurable cost of development, and, when the benefits of the guideline cannot be quantified, the "return on investment" is unknown.

	Strategies to Change Physician Behavior

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Many different strategies are potentially available to change physician practice and implement guidelines. Most, but not all, of the strategies employ different educational interventions.^{4 7} Although education alone can be performed with minimal expense, most studies demonstrate that traditional educational strategies often fail to produce sustained changes in clinical practice.⁴ More intrusive strategies, such as real-time feedback, have proven to be more successful.^{9 10} Therefore, the effectiveness of the educational intervention may determine the eventual success of translating guidelines into clinical practice, and combinations of different strategies may prove most effective. Most studies show that traditional continuing medical education fails to produce changes in clinical practice.^{3 4 7} Change, if it occurs, is short lived, and care usually reverts back to that which occurred prior to the intervention.¹⁰ The failure of education to change practice is concerning, since continuing medical education is often a state licensure requirement for physicians. Although educational mailings may be an affordable intervention, the impact on patient care may be minimal.

Research has demonstrated that physician "opinion leaders," who can be identified using social science techniques, can be influential in changing physician practice.^{11 12} Opinion leaders have been used to change physician behavior and facilitate guideline implementation, including programs to reduce unnecessary cesarean sections, improve blood transfusion practices, and improve the appropriateness of length of stay for patients with chest pain. For example, a Canadian study demonstrated that an educational intervention implemented through opinion leaders significantly reduced inappropriate cesarean sections. A randomized controlled trial measured the effects of opinion-leader dissemination of information and feedback of data in 37 hospitals to improve the care of patients recovering after acute myocardial infarction. For these patients, opinion-leader dissemination of guidelines was associated with an increase in aspirin usage of 17% and ß-blocker usage of 63%.¹² Finally, a study showed that opinion-leader support safely reduced length of stay for patients hospitalized with chest pain.¹³

Retrospective feedback has been shown to have limited impact on patient care.⁶ Although statistically significant changes have been found, the clinical significance has been questioned. Our research has demonstrated limited impact of retrospective feedback on improving preventive care and patient functional status.^{14 15} A meta-analysis of 12 trials of retrospective feedback showed a statistically significant change in clinical practice (odds ratio, 1.091); however, the clinical significance was questionable.⁶

Concurrent feedback, in contrast to retrospective feedback, has been shown to be more effective and result in consistent changes in care.^{5 10} Concurrent feedback can be delivered person-to-person, either face-to-face or over the telephone, or through the display of information on paper or by computer prompts and reminders. Although concurrent feedback can result in significant changes in patient care, our research has demonstrated that when concurrent feedback is withdrawn, care often reverts to that observed prior to initiation of feedback.¹⁰

Computerized clinical decision support can be a cost-effective method of providing concurrent feedback.^{9 16} A review¹⁶ of computerized clinical decision support studies shows that they often lead to improvements in care. Of 65 published computerized clinical decision support studies, 43 studies demonstrated improved care (66%). The number of studies demonstrating benefit were similar for different applications: (1) 9 of 15 drug studies; (2) 14 of 19 preventive-care studies; (3) 1 of 5 diagnostic studies; and (4) 19 of the other 26 studies.¹⁶ Furthermore, improvements in technology will probably make the Internet available for point-of-care applications, and the Internet will become an important vehicle for guideline implementation.

Academic detailing, which is a term for one-on-one education of providers often performed by pharmacists, has been employed as a method of implementing guidelines.¹⁷ In many studies, academic detailing has been found to change physician prescribing practice. Academic detailing has successfully improved transfusion prescribing practices, reduced prescribing of inappropriate medications, and improved the prescribing of effective medications for patients after acute myocardial infarction. For example, a randomized controlled trial was performed to determine whether academic detailing would impact physician adoption of RBC transfusion guidelines.¹⁷ In the group of surgeons who received academic detailing, compliance with the transfusion guidelines increased from 60 to 76%, while in the control group compliance with the guidelines dropped from 60 to 56%. The "return on investment" of this strategy for improving blood transfusion practices was estimated to be approximately 4:1.

Case management, in rigorously performed studies, has been shown to result in minimal changes in care.¹⁸ Of the seven randomized controlled trials examining the use of case managers, only two showed a reduction in resource utilization. Less rigorous case management studies have generally shown greater impact than more rigorous studies.

Physician incentives have been found to significantly change physician behavior.¹⁹ Physician incentives could be used to implement guidelines by directly or indirectly compensating physicians to comply with guidelines. Studies have attempted to discern how incentives influence physician decision making. In one study, physicians who owned their own radiology equipment and could self-refer patients were more than four times more likely to order a radiograph, and radiology charges were 4.4 to 7.5 times greater.¹⁹

Patient education, or "direct-to-consumer" information, has been shown to be an effective method of implementing guidelines. This approach has been proven effective for implementing preventive-care guidelines. For example, in one study women were 50% more likely to receive a mammogram (the odds ratio of getting a mammogram was 1.48) when direct-to-consumer patient education was performed.²⁰

Finally, patient incentives (eg, compensating patients for achieving desired behaviors) have been used as a strategy of achieving desired behavior.²¹ Patient incentives have been shown to have statistically significant and clinically meaningful impact on patient care.

	Conclusion

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Practice guidelines are abundant and have been widely disseminated. Within the past decade, many studies have been conducted to elucidate both the effectiveness and cost of different guideline implementation strategies. These studies have created a sufficient body of knowledge to allow guideline users to sort through a menu of both effective and ineffective guideline implementation strategies. An evidence-based approach to the selection of guideline implementation strategies is likely to yield better results and lead to the translation of guideline recommendations into clinical practice.

	Footnotes

 
Abbreviation: ATS = American Thoracic Society

	References

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7. Oxman, AD, Thomson, MA, Davis, DA, et al (1995) No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 153,1423-1431[Abstract]
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11. Ellrodt, AG, Conner, L, Riedinger, M, et al (1995) Measuring and improving physician compliance with clinical practice guidelines: a controlled interventional trial. Ann Intern Med 122,277-282[Abstract/Free Full Text]
12. Soumerai, SB, McLaughlin, TJ, Gurwitz, JH, et al (1998) Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 279,1358-1363[Abstract/Free Full Text]
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16. Hunt, DL, Haynes, RB, Hanna, SE, et al (1998) Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 280,1339-1346[Abstract/Free Full Text]
17. Soumerai, SB, Salem-Schatz, S, Avorn, J, et al (1993) A controlled trial of educational outreach to improve blood transfusion practice. JAMA 270,961-966[Abstract]
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21. Giuffrida, A, Torgerson, DJ (1997) Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ 315,703-707[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weingarten, S. Search for Related Content PubMed PubMed Citation Articles by Weingarten, S.