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PubMed2006

Development of quality indicators for diagnosis and treatment of patients with non-small cell lung cancer: a first step toward implementing a multidisciplinary, evidence-based guideline.

BACKGROUND: While developing and distributing clinical practice guidelines are important in optimising clinical healthcare, insight into actual care is necessary to achieve successful implementation. Developing quality indicators may be the first step to becoming aware of actual care. The Dutch national practice guideline Non-small cell lung cancer: staging and treatment is one of the first clinical, multidisciplinary guidelines for oncology in the Netherlands for which quality indicators were developed systematically. We describe indicator development based on this guideline as a practical experience. METHODS: To develop a set of indicators for diagnosis and treatment of patients with non-small cell lung cancer, we systematically achieved consensus on the basis of a national, multidisciplinary, evidence-based guideline and the opinions of professionals and patients. After the researchers extracted the recommendations from the guideline, we carried out a so-called Rand-modified-Delphi procedure. This consisted of three rounds: a national panel of professionals and representatives of the national patient organization scored all recommendations, the professionals had a consensus meeting, and the final set of indicators was e-mailed for a last check. Subsequently, some clinimetric characteristics of this final set were assessed in a practice test. RESULTS: Thirty-two of 83 recommendations were selected in the first round. After the consensus meeting, 8 recommendations met the final criteria and were incorporated into 15 indicators, which were tested in practice. The most successful indicators for quality improvement are indicators that are measurable, have potential for improvement, have a broad range between practices and are applicable to a large part of the population. CONCLUSIONS: For successful implementation of evidence-based guidelines, each new guideline should be developed and tested with a set of indicators based on the guideline. The procedure we describe can serve as an example for other new guidelines.

Carcinoma, Non-Small-Cell Lung↗

PubMed2006

Use of clinical practice guidelines by executive directors of optometric associations.

BACKGROUND: The process of developing the American Optometric Association's (AOA) Optometric Clinical Practice Guidelines began in 1989 under the direction of John F. Amos, O.D., M.S., then chair of the AOA's Clinical Care Center. The guideline development process used by the AOA was modeled after the recommendations established by the Agency for Health Care Policy and Research in response to the federal government encouraging health care groups to develop clinical guidelines to enhance the quality, appropriateness, and effectiveness of health care. The guideline topics were chosen for their importance in the education of members, health care payers, and state legislators. A principal author and a consensus panel of experts then were chosen for each subject area. This group was responsible for transforming the latest scientific research and expert judgment into a document that would apply to everyday optometric practice. Thirteen guidelines were developed and mailed to AOA members in 1994 and 1995. Additional guidelines were mailed as they were approved. Currently, there are 20 guidelines available. METHODS: A survey was mailed to the executive director of the optometric association of each state and the District of Columbia and to the chief of optometry of each of the federal services. Telephone follow-up was made to nonrespondents, and an additional copy of the survey was mailed to them with telephone follow-up again taking place for those who did not respond. RESULT: Forty-three of the surveys were returned for a response rate of 78%. Seventy-six percent of the respondents stated that they had received the guidelines. The sections that were found most useful to the respondents were those related to Description and Classification, Basis of Treatment, and Treatment Options. The guidelines were most often used by these groups to improve the quality of eye care, expand optometric involvement in health programs, affect public policy, and overcome problems with insurance groups. DISCUSSION: Optometric organizations have found the clinical practice guidelines useful beyond their primary goal of enhancing the quality of patient care. They have been used effectively to help educate other parties about optometry and its role as a primary health care profession.

Humans↗

PubMed2006

Interventions to improve guideline compliance following coronary artery bypass grafting.

BACKGROUND: Lifestyle modification and appropriate medical therapy improve long-term outcomes following coronary artery bypass grafting (CABG). Our institutional experience suggested that evidence-based recommendations were not being followed postdischarge after CABG. We undertook this study to document our rate of compliance with evidence-based guidelines and to correct deficiencies in our discharge practices. METHODS: Seven evidence-based interventions were studied after CABG: (1) institution of beta-blocker therapy, (2) angiotensin-converting enzyme (ACE) inhibitor therapy, (3) aspirin, (4) lipid-lowering therapy, (5) smoking cessation intervention, (6) heart-healthy diet therapy, and (7) physical activity recommendations. The rate of compliance with guidelines in 50 control patients was measured at discharge. A multidisciplinary team including cardiac surgeons, nurses, dieticians, physical therapists, and clinical pharmacists evaluated the guideline compliance in the control group and developed interventions to assure guideline compliance at the time of discharge. A subsequent study group of 50 patients was then assessed prospectively to measure the guideline compliance after institution of intervention programs. The multidisciplinary team agreed on predefined acceptable compliance limits as follows: (1) >80% of patients receive ACE inhibitors at discharge, (2) 100% of patients receive beta-blockers, aspirin, and lipid-lowering agents at discharge, and (3) 100% of patients receive lifestyle modification counseling at discharge. Compliance with guidelines was defined as documentation in the medical record of provision of medications and lifestyle counseling at the time of discharge. RESULTS: In the control group, the rate of guideline compliance was surprisingly low. Rates of compliance with guidelines increased significantly after the multidisciplinary interventions were undertaken. CONCLUSIONS: We conclude that compliance with guidelines known to improve long-term outcome is suboptimal after CABG. A multidisciplinary intervention program can improve compliance with currently accepted guidelines and quality indicators in patients following CABG.

Adrenergic beta-Antagonists↗

PubMed1997

Computerized decision support based on a clinical practice guideline improves compliance with care standards.

PURPOSE: Clinical guidelines are designed to assist in the management of specific diseases; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record. SUBJECTS AND METHODS: In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care. RESULTS: Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group. CONCLUSION: Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care.

Decision Making, Computer-Assisted↗

PubMedDate not supplied

Major depressive disorder in the general hospital: adaptation of clinical practice guidelines.

Major Depressive Disorder is particularly frequent among physically ill inpatients. Despite the considerable human burden and financial costs, Major Depressive Disorder remains under-detected and under-treated. To improve this situation, clinical practice guidelines for the management of Major Depressive Disorder were developed for patients in the general hospital. They were adapted from existing good quality guidelines. A literature search has been conducted to identify guidelines and systematic reviews about the management of Major Depressive Disorder. The quality of the existing guidelines was evaluated by means of the AGREE instrument (Appraisal of Guidelines for Research and Evaluation). Complementary literature searches were necessary to answer questions such as "depression and physical illness" or "antidepressants and somatic medication". The guidelines were discussed by a multidisciplinary internal panel. The final version was reviewed by an external panel. This paper presents the development process and a summary of these guidelines for the management of Major Depressive Disorder. The adaptation of good quality guidelines to local needs requires much time, effort and skills. Easier ways for the adaptation and use of high quality guidelines at the local level may result from better coordination, organization and updating of guidelines at a national or supranational level.

Major Depressive Disorder↗

PubMed2002

Verification of temporal scheduling constraints in clinical practice guidelines.

The computerization of clinical practice guidelines is a significant scientific challenge for the medical informatics community. One frequently reported factor hindering this objective is the existence of deficiencies within guideline knowledge. In this paper, we focus on the detection of flaws within temporal scheduling constraints. Temporal scheduling constraints are important elements of therapy management, and are frequently incorporated in clinical practice guidelines. We present a suitable verification method that is based on calculating the minimal network of temporal constraints on the execution of guideline activities. Our method serves three purposes: (1) it checks whether temporal scheduling constraints are consistent with scheduling constraints implied by control flow operators and the hierarchical structuring of a guideline; (2) it yields suggestions for an equivalent, yet more explicit representation of non-minimal constraints; (3) it can be used by the guideline interpreter to assemble feasible time intervals for the execution of each guideline activity. We evaluate our approach by applying it to a guideline specified in the Asbru language. For this purpose, we implemented a prototype verifier. Although we concentrate on the guideline representation language Asbru as the demonstration medium of our method within this paper, our approach can be reused to verify several alternative guideline representation formats.

Humans↗

PubMed2001

Can practice guidelines be transported effectively to different settings? Results from a multicenter interventional study.

RATIONALE: Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings. METHODS: In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience. RESULTS: Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of > or = 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice. CONCLUSIONS: Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.

Aged↗

PubMed1996

Mechanism of action and impact of a cystitis clinical practice guideline on outcomes and costs of care in an HMO.

BACKGROUND: A study was conducted in 1995 at five primary care clinics of a staff-model health maintenance organization in the Midwest to assess the impact of a cystitis clinical guideline and to help elucidate the guideline implementation process. METHODOLOGY: Two hundred one eligible women with uncomplicated cystitis were treated in a three-month period before the guideline, and 241 similar cases were treated in a three-month period after the guideline. Nursing supervisors and clinic managers at each clinic were interviewed about how the cystitis guideline was implemented at each clinic. RESULTS: Use of a recommended three-day antibiotic treatment increased from 28% to 52% of cases (chi-square = 25.01, p < 0.001). Use of urine cultures decreased from 70% to 37% of cases (chi-square = 48.19, p < 0.001). The proportion of eligible cystitis cases coordinated primarily by the nurse increased from 21% to 78% (chi-square = 142.93, p < 0.001). However, desired changes in use of antibiotics and urine cultures were limited to nurse-coordinated cases. There was no increase in hospital admissions, emergency room visits, repeat office visits (p > 0.05), or repeat antibiotic courses (p > 0.05) after cystitis guideline implementation. Cost of cystitis care delivered after guideline implementation was 35% lower than before guideline implementation. CONCLUSIONS: Use of the guideline was associated with desirable changes in antibiotic use, nurse coordination of care, costs of care, and comparable clinical outcomes. Clinics that used clinical systems and tools to support nurse-coordinated cystitis care had greater guideline adherence than clinics that did not support nurse-coordinated care.

Adult↗

PubMed2001

Cognitive psychological studies of representation and use of clinical practice guidelines.

Clinical practice guidelines provide a means to enhance physician performance. This investigation was undertaken in an attempt to understand the nature of impact of guideline use on physician performance. We investigated the impact of (a) algorithmic-based and (b) text-based practice guidelines on clinical decision-making by physicians at varying levels of expertise. Data were collected using clinical scenarios and a think-aloud paradigm, both with (primed) and without (spontaneous) the use of the guidelines. The two guidelines used in the study were management of diabetes and screening for thyroid disease. The results show that guidelines were used as reminders for both experts and non-experts. Guidelines acted as an educational tool for non-experts by assisting in knowledge reorganization, particularly for the non-experts. Text and algorithmic guideline formats were both useful to physician performance depending on the purpose of use: solving clinical problems or learning. These results provide insights into how guidelines can be fine-tuned for different users and for different purposes. Empirical research, coupled with design principles from the cognitive sciences, can form an essential component of guideline design and development.

Adult↗

PubMed2005

The impact of implementing national hypertension guidelines on prevalence and workload in primary care: a population-based survey of older people.

Recently revised UK and US hypertension guidelines have reduced thresholds for both diagnosis and treatment and differ in their recommendations. We have used data from a random, stratified community-based sample of 4784 people aged 65 years and over to compare the prevalence of treatable hypertension and the potential impact on patients and primary care from using current guidelines. BHS, NICE and JNC7 guidelines were applied to blood pressures obtained from primary care medical records (94%) or measured at a screening clinic (6%). Risk factors were obtained by questionnaire and from medical records, supplemented by epidemiological data. Workload was estimated for a representative practice population of 10 000 patients. Blood pressures were obtained on 4514 patients (94%). Prevalence of treatable hypertension was over 67%. Compared to BHS4, prevalence estimates using NICE guidelines were comparable for men but significantly lower for women (P<0.05). They were significantly higher using JNC7 compared with BHS4 and NICE guidance (P<0.05). A general practice of 10 000 patients could expect 1287 older hypertensive patients using BHS4 guidelines and 1231 patients using NICE guidelines. Under BHS4, an extra 94 patients will require annual, rather than 5-yearly review compared with that using the previous guideline. In conclusion, implementation of BHS4 guidelines, with their revised thresholds for diagnosis, will not add materially to the prevalence of treatable hypertension compared to previous BHS3 guidelines but will have a major impact on practice workload. Use of NICE guidelines in preference to BHS4 will result in GPs treating fewer patients and reviewing untreated patients less often.

Aged↗

PubMed1998

Guidelines for every person.

Guidelines, it is assumed in health care circles, have worth. In the ideal health care system they may offer everything from medical certainty to legal protection. They have the potential to save practitioners from the trauma of indecision and at the same time protect them from the consequences of wrong decisions. In this paper, I discuss the impact of guidelines on general practitioners and consumers. Both groups are at the effector end where guidelines should have maximal impact. It is primarily medical practitioners and their constituents in the long run that have to make guidelines work. Theoretical questions about the essential worth of guidelines for consumers and general practitioners are explored, as well as the more practical issues of utility of guidelines. My hypothesis is that guidelines may be conceptually worthwhile, but as yet are of unproven utility. This argument is traced through the literature surrounding the involvement of general practitioners and consumers in guideline development, implementation, review and relevance. From this information a new role for guidelines which is cogniscent of the needs and circumstances of the end users is postulated. Guidelines can become the basis for the principles of sound clinical practice which allow for the unique individual circumstances of clinical practice whilst also providing a consolidated basis for this practice.

Australia↗

PubMed1999

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

Consumer Behavior↗

PubMed2002

Responses of primary health care professionals to UK national guidelines on the management and referral of women with breast conditions.

RATIONALE, AIMS AND OBJECTIVES: To explore the responses of primary health care professionals to guidelines in general, and to the UK national guidelines on the management and referral of women with breast conditions in particular. METHODS: Qualitative study using practice-based, semistructured group discussions with primary health care professionals. All practices were involved in a study evaluating the effect of the national breast symptom management guidelines on clinical practice. Discussion groups were conducted in the practice; fifteen of the 34 study practices were audio-taped. Groups comprised the available partners and practice nurses at each practice. All members of each group were well known to one another. There was good attendance by all doctors, with 75% of male partners and 90% of female partners present at the meetings. Of the practice nurses 51% attended. In all, 86 professionals attended the meetings. RESULTS: A number of areas for comment arose consistently in each discussion. Guidelines in general were welcomed, although there was more support for evidence-based than consensus-based guidelines. The breast lump guideline was also welcomed, participants commenting that it was concordant with current practice. The breast pain guideline was more contentious, participants reflecting that it recommended more primary care management than was usual, and fell outside the experience and confidence of doctors or the expectations of patients. Participants felt it did not incorporate psychosocial factors into recommended management, despite this being an important part of primary care management. CONCLUSIONS: There are concerns about consensus guidelines and doubts about the applicability of the breast pain guideline in this complex management area. The failure of these guidelines to address patient anxiety may limit their implementation.

Attitude of Health Personnel↗

PubMedDate not supplied

Guidelines for the diagnosis of osteoporosis by densitometric methods.

BACKGROUND: Osteoporosis is a major health hazard for postmenopausal women and elderly people. Local, national, and international organizations developed clinical practice guidelines for the diagnosis and management of osteoporosis and the prevention of osteoporotic fractures. Low bone mineral density (BMD) is the most important risk factor for fragility fractures. Bone densitometry is the best method to measure BMD in an individual. Many risk factors contribute to the development of osteoporosis and increase the fracture risk independently from BMD. Guidelines must be comprehensive, factual, simple to implement, and should provide the clinician, patients, governments, and payers with the best evidence available. OBJECTIVES: The objectives of this article were to review national and international guidelines to establish a congruent set of parameters that may aid the clinician in the decision-making process for the diagnosis of osteoporosis. DATA SOURCES: An online search of several databases provided 18 guidelines for this review. Comparison among the guidelines was made on 10 different aspects: format, focus, significance of hip and vertebral body fractures, primary diagnostic considerations, BMD measurement technology, interpretation, reporting and follow-up, equipment reliability and quality control, risk factors considered, and methodologic quality of the guidelines. Tables were created for easier comparison on the aspects covered and supported by each guideline. RESULTS: None of the guidelines reviewed fulfills all the requirements of good clinical practice guidelines. CONCLUSIONS: Further works should finally provide all those interested with a more complete and thorough set of guidelines based on the best evidence available.

Aged↗

PubMed2004

Critical evaluation of the existing guidelines on mild traumatic brain injury.

The purpose of guidelines is to reduce practice variability, but they need to be evidence-based. We examine current mild traumatic brain injury guidelines, critique their basis in evidence and examine their variability in recommendations. A systematic search of the literature found 38,806 abstracts, with 41 guidelines. There were 18 sports-related guidelines, 13 related to admission policies, 12 related to imaging and 5 related to neuropsychological assessment. Some guidelines addressed several areas. Only 5 guidelines reported a methodology for the assembly of evidence used to develop the guideline. After appraising the guidelines against a validated index, we found that 3 of the 41 guidelines could be categorized as evidence-based. Two of these focused on paediatric patients and 1 on adult patients. Limited methodological quality in the current guidelines results in conflicting recommendations amongst them.

Advisory Committees↗

PubMed2003

Analysis of some variables concerning guidelines adopted in a hospital in Milan: quantity, quality and physicians' attitude; which is the reciprocal influence of these factors?

BACKGROUND: Starting in 1998 the Italian NHS promoted the adoption of practice guidelines without, however, launching directions on how they should be produced and adopted. The aim of the current work was to explore the relationship between number and quality of guidelines and physicians' attitudes towards them. METHODS: All documents named 'guidelines' adopted after 1998 by each unit at the San Paolo Hospital (SPH), a 600-bed university hospital were collected. The quality of these guidelines was assessed according to a seven point scale looking at methodological quality and completeness of reporting. A 16-item questionnaire was delivered to all physicians of the SPH investigating barriers affecting their attitude towards adopting guidelines. The correlation between quantity and quality of guidelines and physicians' attitude was explored. RESULTS: In total, 319 documents from 19 units were examined. The overall quality varied across units and was generally poor (range: 0.5-3 items satisfied per guideline). Of the 392 physicians sampled, 301 filled in the questionnaire, and a positive attitude to guidelines was found. None of the relationships analysed--quantity, quality and attitude--turned out to be significantly associated. CONCLUSIONS: This study highlights contrasting results. The number of recorded documents and physicians' attitude indicate a vivacious interest in guidelines even if the quantitative production was extremely variable among units and the quality was unsatisfactory. This scenario may suggest a transition period in which the lack of a solid methodological background in the production and adoption of guidelines runs into the need to be compliant to a new rule.

Attitude of Health Personnel↗

PubMed2003

Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs.

OBJECTIVE: To describe systematically the structures and working methods of guideline programs. DESIGN: Descriptive survey using a questionnaire with 32 items based on a framework derived from the literature. Answers were tabulated and checked by participants. STUDY PARTICIPANTS: Key informants of 18 prominent guideline organizations in the United States, Canada, Australia, New Zealand, and nine European countries. MAIN OUTCOME MEASURES: History, aims, methodology, products and deliveries, implementation, evaluation, procedure for updating guidelines, and future plans. RESULTS: Most guideline programs were established to improve the quality and effectiveness of health care. Most use electronic databases to collect evidence and systematic reviews to analyze the evidence. Consensus procedures are used when evidence is lacking. All guidelines are reviewed before publication. Authorization is commonly used to endorse guidelines. All guidelines are furnished with tools for application and the Internet is widely used for dissemination. Implementation strategies vary among different organizations, with larger organizations leaving this to local organizations. Almost all have a quality assurance system for their programs. Half of the programs do not have formal update procedures. CONCLUSIONS: Principles of evidence-based medicine dominate current guideline programs. Recent programs are benefiting from the methodology created by long-standing programs. Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors. International collaboration should be encouraged to improve guideline methodology and to globalize the collection and analysis of evidence needed for guideline development.

Consensus↗

PubMed1997

From clinical guidelines to quality assurance: the experience of Assistance Publique-Hôpitaux de Paris.

OBJECTIVES: The objectives of this study are: to present the history of the development of clinical guidelines in France. to present the implementation of a program of clinical guidelines in Assistance Publique-Hôpitaux de Paris (AP-HP), the regional public hospital system of the Paris metropolitan area, and to discuss the lessons learned from this program, which provide a basis for a better policy of guidelines at a national level. CONTENT: The objective of the AP-HP program is to promote the appropriate use of clinical guidelines and to evaluate their impact on quality of care and/or costs. Experiments such as controlled trials are used to test the effectiveness of some implementation strategies, to verify that guidelines do improve the process of care and to improve physician compliance with clinical guidelines. Guidelines are developed in a context of budget constraint, and the general aim of the program is to promote the more efficient use of available health resources. RESULTS: In a context of health care inflation, the desire of public authorities is to use guidelines as a tool for cost control strategy, either for ambulatory care or for hospitals. AP-HP experience shows that it is very difficult to develop a national program of clinical guidelines and to implement it in every hospital, as was done in France (but not clearly evaluated) in ambulatory care (under the name 'references médicales'). Guidelines need to be locally adapted, and the best implementation strategies depend on local resources, for example the existence of a pertinent information system. The role of financial incentives is present in French policies, and the role of the drug industry needs to be evaluated.

France↗