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PubMed2004

Facilitating knowledge maintenance of clinical guidelines and protocols.

Clinical protocols and guidelines are widely used in the medi-cal domain to improve disease management techniques. Different software systems are in development to support the de-sign and the execution of such guidelines. The bottleneck in the guideline software developing process is the transformation of the text-based clinical guidelines into a formal representation, which can be used by the execution software. This paper introduces a method and a tool that was designed to provide a solution for that bottleneck. The so-called Guideline Markup Tool (GMT) facilitates the translation of guidelines into a formal representation written in XML. This tool enables the protocol designer to create links between the original guideline and its formal representation and ease the editing of guidelines applying design patterns in the form of macros. The usefulness of our approach is illustrated using GMT to edit Asbru protocols. We performed a usability study with eight participants to examine the usefulness of the GMT and of the Asbru macros, which showed that the proposed approach is very appropriate to author and maintain clinical guidelines.

Clinical Protocols↗

PubMed2006

[Consumer involvement in the Disease Management Guideline for Asthma--a background report].

In the past clinical guidelines were mainly developed by experts and in everyday clinical practice almost exclusively used by clinical experts, while issues that were relevant from the patients' (consumers') point of view tended to be neglected. But then, the majority of patient information has not been perceptibly connected to clinical guidelines. Connecting the development of clinical guidelines with the development of patient information publications would make good sense for both products, though. On the one hand, evidence-based treatment guidelines could be made available to the actual target group of the clinical care process--i.e. the patients or consumers--and on the other hand, patient experiences and competencies (social evidence) might inform the production of guidelines. Such a procedure demands the cooperation of clinical experts and patients. So far there are no generally accepted methods in Germany for the practical implementation of consumer involvement on both the organizational and content level with the aim of involving patients in the development process of guidelines as well as the production of the respective patient information versions. Such a methodology shall be established as part of the National Program for Disease Management Guidelines. For the first time in this program, patient involvement is being exercised within the scope of the National Disease Management Guideline for Asthma (NDM Asthma). Here, patients are involved in the NDM development process by providing the opportunity to comment on the consented guideline draft and to participate in the translation of the NDM Asthma into a patient version. The present paper is a background report describing the current state of work and indicating consequences for some future developments.

Asthma↗

PubMed1990

Recommended guidelines for infant hearing screening: analysis.

This paper has identified problems with the guidelines and the disadvantages of the ASHA protocol. Some of these are significant. Others are less important but represent issues that should be considered when designing an EID protocol. The problems and disadvantages are summarized below. 1. The guidelines should have estimated and cost and performance of the recommended protocol. 2. The guidelines should have identified the true advantage of ABR screening (lower cost) and the disadvantage (lower hit rate) as compared to other protocols. 3. The guidelines should have evaluated other possible protocols. 4. The guidelines recommended the same protocol for all facilities (with adequate resources) independent of local factors. 5. The guidelines recommended the same screening strategy for the ICN and the WBN when different protocols may be appropriate. 6. The guidelines reject ABR screening of all WBN infants as too expensive without estimates of cost. More importantly, this is a decision that should be made by local institutions or governments. 7. The screening protocol was developed without a detailed description of the diagnostic component of the EID protocol. 8. The guidelines should have provided more information to hospitals that do not have the resources necessary to implement the recommended protocol. 9. The recommended protocol requires significant in-patient testing that can cause problems with reimbursement. 10. Some infants at risk for progressive loss can be lost from follow-up. Apparently, the guidelines were developed using a subjective, experiential approach. Although clinical experience is important, subjective impressions can be subject to bias and error. Some type of quantitative analysis is essential when developing test protocols. Perhaps a more rigorous theoretical foundation is needed to focus research and guide the development of EID protocols. The ASHA protocol is reasonable, but there is little evidence indicating that it is superior to, or even as good as, other possible protocols. Like all protocols, it has advantages and disadvantages. That is not to say that all possible protocols are appropriate. For example, protocols that delay diagnostic testing beyond 6 months should be rejected if the goal is habilitation by 6 months. Protocols that use screening tests with extremely poor hit rates may be undesirable in most situations. There remains one fundamental question. Is it even appropriate to recommend a particular protocol when, by necessity, many important local factors must be ignored? Perhaps it would be better to provide the basic data and techniques that would permit audiologists to design EID protocols that are optimum for their own circumstances.

American Speech-Language-Hearing Association↗

PubMed1995

Clinicolegal aspects of practice guidelines for pediatric eye and vision examination.

BACKGROUND: The American Optometric Association (AOA) recently joined a growing trend in the health care professions by adopting clinical practice guidelines. The goals of practice guidelines are to improve quality of care and to provide a more objective measure of standard of care for the legal system and the health insurance industry. Practice guidelines may eventually reduce the number and cost of malpractice actions. Historically, the standard of care for pediatric eye and vision examination has been the subject of controversy. Issues of disagreement include the amount of ocular health testing that should be performed and the determination of appropriate emphasis on functional vision. This paper summarizes the precedents that have established a legal standard of care for pediatric eye and vision examination. METHODS: A review of malpractice claims relevant to pediatric optometry was conducted. Public health policy, legal, and malpractice literature was also consulted for current views on practice guidelines. The recent AOA Optometric Clinical Practice Guidelines for Pediatric Eye and Vision Examination were compared to this review. RESULTS: Standards of care for pediatric eye examination should minimally include assessment of visual acuity, refractive error, binocular vision, functional vision, and eye health assessment including dilated funds examination with a binocular indirect ophthalmoscope. These standards are commensurate with the AOA Guidelines. CONCLUSIONS: The AOA Optometric Clinical Practice Guidelines for Pediatric Eye and Vision Examination is compared to the current standard of care for pediatric optometry. It is concluded that the Guidelines are appropriate. Optometrists should integrate these practices into patient care, and the optometric profession should seek to obtain wide spread acceptance of the Guidelines.

Adolescent↗

PubMed1995

Ribavirin therapy: implementation of hospital guidelines and effect on usage and cost of therapy.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends that ribavirin be reserved for infants who are severely ill and who are at high risk of morbidity and mortality, based on underlying clinical conditions. The purpose of this study was to evaluate current ribavirin use in our institution, implement hospital-specific guidelines for use, develop a prospective surveillance system to monitor ribavirin therapy, and evaluate the impact of these guidelines on subsequent use and cost of therapy. METHODS: Ribavirin use was compared with the recommendations of the AAP. Results were presented to the professional staff, and hospital guidelines were implemented. Ribavirin therapy was reevaluated in a 2-year period after hospital guidelines were implemented. RESULTS: In the initial evaluation period, only 67% of the ribavirin recipients met the AAP guidelines for use, and 19% received an inappropriate treatment regimen. The total cost and billed patient charges for ribavirin recipients who did not meet the guidelines for use in period 1 was $60,638 and $127,940, respectively. Over the next 2 years (period 2) after the implementation of hospital guidelines, the percentage of patients who received ribavirin decreased 35%, and approximately 96% of ribavirin recipients met the established criteria. Based on the decrease in the percentage of patients who received ribavirin in period 2 (41% versus 63%), the estimated cost avoidance and reduction in billed patient charges in period 2 was $55,540 and $117,334, respectively. This represents an estimated reduction in hospital costs and billed patient charges of $46,283 and $97,778 per 100 admissions for acute bronchiolitis. CONCLUSIONS: Before the implementation of hospital guidelines for use, a substantial percent of patients received ribavirin not consistent with the recommendations of the AAP. Following the adoption of a modified version of the AAP guidelines for our institution and the use of a multidisciplinary surveillance system for monitoring ribavirin therapy, we observed a substantial decrease in the overall ribavirin use. This has resulted in a significant savings in terms of cost avoidance and reduced billed patient charges.

Drug Costs↗

PubMed1994

Conformity with guidelines for antimicrobial prophylaxis against bacterial endocarditis.

The extent to which prescribed antimicrobial prophylaxis against bacterial endocarditis conformed with American Heart Association (AHA) guidelines was determined and the frequency of nonconformity with specific elements of the guidelines was evaluated. Patients with conditions defined by AHA as placing them at risk for developing endocarditis were identified through medical records for a four-year period at an 850-bed hospital. Data about the procedures they underwent and prophylaxis prescribed were compared with the AHA guidelines. Conformity with the guidelines was evaluated according to whether prophylaxis was recommended, optional, or unnecessary; nonconformity with specific elements of the guidelines (indication, choice of antimicrobial, dose, dosage interval, timing, and duration) was also evaluated. The following variables were evaluated for possible association with nonconformity to the guidelines: patient's age and sex, penicillin allergy, use of a consultant, and whether the procedure was the first performed in the patient after identification of the cardiac condition. Of the 131 cases analyzed, 29 (22%) involved prophylaxis that conformed with the AHA guidelines. Conformity with the guidelines was significantly lower when prophylaxis was recommended or optional than when it was unnecessary. Nonconformity was most common with the following elements: indication, choice of antimicrobial, and dose. Recommended prophylaxis was given more often in children than in adults and more often before first procedures than before subsequent procedures. More of the regimens prescribed for children exceeded the recommended duration than those prescribed for adults. Unnecessary prophylaxis was given more often when a consultant was involved than when no consultant was involved. In hospitalized patients, conformity with AHA guidelines for antimicrobial prophylaxis against endocarditis was low.

Adolescent↗

PubMed1994

Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination.

BACKGROUND: The Royal College of Radiologists' guidelines aim to encourage more appropriate use of diagnostic radiology and so reduce the use of clinically unhelpful x-ray examinations. AIM: The object of this study was to conduct a randomized controlled trial of the introduction of the guidelines into general practice. METHOD: A total of 62 practices (170 general practitioners) referring patients to St George's Hospital, London for diagnostic radiology were randomly allocated into two groups. Guidelines were sent to the 30 practices in the intervention group. Radiological referral patterns were compared in both groups before and after the introduction of guidelines. RESULTS: Practices which had received guidelines requested significantly fewer examinations of the spine, and made a significantly higher proportion of requests which conformed to the guidelines compared with practices which had not received the guidelines. There were no significant differences in the proportion of forms giving physical findings or in the proportion of positive findings at radiology. CONCLUSION: Introduction of guidelines can influence general practitioners' radiological referrals in the short term. Wider use of guidelines might help to reduce unnecessary irradiation of patients.

Adolescent↗

PubMed1995

The role of oncology clinical practice guidelines in the managed care era.

The development of clinical practice guidelines in oncology presents unique problems and challenges due to the heterogeneity of disease presentations and the complexity of therapeutic decisions. Guidelines should incorporate not only standard outcomes measures such as survival but, if feasible, quality of life measures, patient preferences, and cost-effectiveness analyses. Although clinical guidelines are being promulgated as a means of assisting physicians in making therapeutic decisions, another purpose of guidelines implementation reflects the goals of managed care, ie, to promote practice conformity and reduce the cost of care. Methods to monitor physicians' adherence to guidelines are expected to increase as a means of ensuring compliance. This article reviews the process of developing two common types of guidelines used in oncology: path guidelines (using stage II breast cancer as a paradigm) and boundary guidelines (such as the ASCO growth factor guidelines).

Humans↗

PubMed1996

Compliance with guidelines results in appropriate ondansetron prescribing at Christchurch Hospital.

AIM: To assess compliance with established consensus derived guidelines for ondansetron therapy and to estimate the cost of any non-guideline use. METHODS: All inpatients (including paediatric patients) at Christchurch Hospital who received ondansetron during August 1993 were identified by daily review of medication charts. Outpatients who received ondansetron prescriptions were identified from pharmacy records. All patients' medical records were then examined and ondansetron therapy was compared with the guideline recommendations for indication and dosage. The total cost of ondansetron for each patient was also calculated. RESULTS: Ondansetron was prescribed for 64 patients (41 female, 23 male) during the one month period. Fifty patients received ondansetron therapy in accordance with all indication and dosage aspects of the guidelines. The main guideline indication for use was highly emetogenic chemotherapy with 28 patients. Fifteen patients received ondansetron because of failure of standard antiemetic therapy and nine because they were paediatric chemotherapy patients. Of the 12 patients who received ondansetron outside the guidelines indications, nine had received 'moderately highly' emetogenic chemotherapy (whereas the guidelines state 'highly' only), two had severe asthma, one received radiotherapy. Two patients did not comply with the dosage recommendations as they received ondansetron more than 24 hours after the initial cytotoxic dose. Total ondansetron expenditure for the period was $12,789 (inpatient $8492 outpatient $4297). Expenditure related to the nonguideline usage was $536 (4.2% of the total monthly ondansetron expenditure). CONCLUSION: There was high compliance with the guidelines. This supports the use of guidelines in encouraging appropriate prescribing.

Adult↗

PubMedDate not supplied

The future impact of clinical practice guidelines.

Clinical guidelines are a very hot topic. Many guidelines are being published, but many concerns about guidelines still exist. Guidelines may be able to increase the quality of health care while eliminating unnecessary or inappropriate care. Critics wonder if the process will instead lead to poorer care and a waste of time and effort. Although guidelines are targeted on providers of care, those with other roles will use guidelines for optimizing patient care and outcomes, assuring quality, cutting costs and tracking liability and risk management. Examination of guidelines and their impact suggest that the process and product are imperfect and that the impact is difficult to measure. The chiropractic profession will continue in its guideline efforts. The direct effects of guidelines will be on certain aspects of doctor knowledge, attitude, belief and behavior. The indirect effects will be largely attitudinal in nature at first but will eventually lead to action. The profession will embrace the need to (a) develop a more comprehensive and useful research database and (b) to develop sophisticated means for obtaining profession-wide consensus on fundamental clinical issues.

Chiropractic↗

PubMed1996

The use of empiric clinical data in the evaluation of practice guidelines for unstable angina.

OBJECTIVE: To determine the applicability to emergency department (ED) clinical practice of a nationally disseminated practice guideline on the disposition of patients with a diagnosis of unstable angina, and to determine the potential impact of the guideline on hospital admissions and demand for intensive care beds. DESIGN: Application of guideline criteria for ED disposition decisions to a validation sample derived from a prospective clinical trial. SETTING: Five hospitals, including 2 urban general teaching hospitals, 2 urban tertiary care university hospitals, and 1 suburban university-affiliated community hospital. PATIENTS: A consecutive sample of 457 patients who presented with symptoms suggestive of acute cardiac ischemia and who had "unstable angina" or "rule out unstable angina" diagnosed by ED physicians. Greater than 90% of eligible patients were enrolled in the clinical trial; follow-up data sufficient for assignment of a definitive diagnosis were obtained for 99% of subjects. MAIN OUTCOME MEASURES: Acute myocardial infarction and unstable angina, based on blind review of initial and follow-up clinical data, including cardiac enzyme levels and electrocardiograms. After completion of the trial, without knowledge of final diagnosis or outcome, the investigators classified patients into risk groups specified by the unstable angina guideline. RESULTS: Of subjects with an ED diagnosis of unstable angina, only 6% (n=28) met the guideline's criteria corresponding to low risk for adverse events and were therefore suitable for discharge directly to home. Fifty-four percent (n=247) met the intermediate-risk criteria; 40% (n=182) met the high-risk criteria and were identified as requiring admission to an intensive care unit. Actual ED disposition differed from guideline recommendations in 2 major areas: only 4% (1/28) of low-risk patients were discharged to home with outpatient follow-up, and only 40% (72/182) of high-risk patients were admitted to an intensive care unit. CONCLUSIONS: Although the guideline was intended to reduce hospitalization by identifying a low-risk group, the small size of this group among ED patients suggests that little reduction in hospitalization can be expected. Indeed, the guideline may increase demand for the limited number of intensive care beds to accommodate patients with unstable angina considered high-risk but currently placed elsewhere. These results emphasize the need to use empiric data from target clinical settings to assess the likely actual impact of guidelines on clinical care prior to national dissemination.

Angina, Unstable↗

PubMed1997

[Guidelines and their observance in the psychiatric care of failed suicides in general hospitals].

OBJECTIVE: To gain insight into the guidelines established for the care of failed suicides in general hospitals, and into the degree to which these guidelines are observed in practice. DESIGN: Descriptive, retrospective. SETTING: Department of Psychiatry, Rijnstate Hospital, Arnhem, the Netherlands. METHOD: An inventory of guidelines for the care of failed suicides was made by interviewing seven psychiatrists on the staff of general hospitals. The inventory was limited to access (interval between admission and referral/consultation), and the coordination of the care (i.e. adjustment to the patient's condition, transfer of information). Subsequently, the cases of all failed suicides admitted to these hospitals in 1991 were studied to find out how these guidelines were observed in practice; use was made for this purpose of data from a more extensive European study. RESULTS: All seven hospitals proved to have rules for coping with tailed suicides. Guidelines concerning accessibility of care were fairly similar in the various hospitals; regarding the coordination of care, more local variants were found to exist. The accessibility of care was found to be mostly in accordance with the guidelines. There were more deviations from the guidelines where the coordination of care was concerned; in addition, there were substantial differences between the hospitals in the degrees to which deviation from the guidelines occurred. CONCLUSION: Guidelines for the care of failed suicides admitted to general hospitals were not in all respects similar; the observance differed markedly, especially regarding the coordination of care.

Adolescent↗

PubMed1997

[Guidelines for clinical practice].

Clinical practice guidelines are systematically developed statements that are intended to support medical decision making in well-defined clinical situations. Essentially, their object is to reduce the variability in medical practice, to improve quality, and to make appropriated control of the financial resources possible. Internationally, ever more organisations, associations, and institutions are concerned with the development of guidelines in many different areas of care. Making implicit knowledge explicit is one of the associated advantages of guidelines: they have a potential utility in training, in process evaluation, and in the reevaluation of outcome studies. In liability issues, their existence has a double effect: they can be used to justify medical behaviour, and they constitute a generally accepted reference point. A derivative problem is the legal liability of the compilers of the guidelines. The principle of the guideline approach can be challenged academically: science cannot give a definition of optimal care with absolute certainty. What is called objectivity often rests on methodologically disputable analyses; also the opinion of opinion leaders is not always a guarantee for scientific soundness. Moreover, patients are not all identical: biological variability, situational factors, patient expectations, and other elements play a role in this differentiation. Clinicians are often hesitant with respect to clinical guidelines: they are afraid of cookbook medicine and curtailment of their professional autonomy. Patients fear reduction of individualization of care and the use of guidelines as a rationing instrument. The effects of the introduction of clinical practice guidelines on medical practice, on the results and on the cost of care vary but are generally considered to be favourable. The choice of appropriate strategies in development, dissemination, and implementation turns out to be of critical importance. The article ends with concrete suggestions for the various steps in the development of guidelines and their actual compilation.

Adolescent↗

PubMed2002

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions.

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with the biological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Adolescent↗

PubMed2002

Report of the Japan Atherosclerosis Society (JAS) Guideline for Diagnosis and Treatment of Hyperlipidemia in Japanese adults.

This paper described the Guideline for Diagnosis and Management of Hyperlipidemias for Prevention of Atherosclerosis proposed by The Japan Atherosclerosis Society (JAS) Guideline Investigating Committee (1,995-2,000) under the auspices of the JAS Board of Directors. 1) The guideline defines the diagnostic criteria for serum total cholesterol (Table 1), LDL-cholesterol (Table 1), triglycerides (Table 4) and HDL-cholesterol (Table 7). It also indicates the desirable range (Table 1), the initiation levels of management (Table 2) and the target levels of treatment (Table 2) for total and LDL-cholesterol. 2) Though both total and LDL-cholesterol are shown as atherogenic parameter in the guideline, the use of LDL-cholesterol, rather than total cholesterol, is encouraged in daily medical practice and lipid-related studies, because LDL-cholesterol is more closely related to atherosclerosis. 3) Elevated triglycerides and low HDL-cholesterol are included in the risk factors, since no sufficient data have been accumulated to formulate the guideline for these two lipid disorders. 4) Emphasis is laid on evaluation of risk factors of each subject before starting any kind of treatment (Table 2). 5) This guideline is applied solely for adults (age 20-64). Lipid abnormalities in children or the youth under age 19, and the elderly with an age over 65 have to be evaluated by their own standard. 6) This part of the guideline gives only the diagnostic aspects of hyperlipidemias. The part of management and treatment will follow in the second section of the guideline that will be published in future.

Adult↗

PubMed2005

Canadian guidelines for the management of benign prostatic hyperplasia.

OBJECTIVE: To develop the first Canadian guidelines for the management of lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH). METHODS: These guidelines, developed under a mandate provided by the Canadian Urological Association (CUA), were a collaborative effort between the CUA guidelines committee and the Canadian Prostate Health Council. BPH guidelines developed by the American Urological Association, the European Association of Urology, the World Health Organization International Consultation on BPH, and similar committees from Germany, Sweden and Australia were reviewed. The committee further reviewed a systematic literature search, updated to May 2004, and systematically derived Canadian urological opinion data. RESULTS: The subsequent Canadian BPH guidelines were developed as an evidence based consensus among the committee members. Mandatory evaluation includes history, physical examination and urinalysis, while a symptom inventory and PSA in selected patients are recommended. Serum creatinine, uroflow, voiding diary, post void residual and sexual function questionnaire are optional. Unless there is an indication, other related tests are not recommended. Treatment choices should be governed by the severity of the symptoms, bother and patient preference. Guidelines for medical, surgical and minimally invasive treatment as well as special considerations are described in terms of guideline, option and recommendation. CONCLUSIONS: Diagnostic and treatment guidelines for BPH reflect the Canadian social priorities, economics, socialized medical practice, manpower issues, and medicolegal considerations.

Canada↗

PubMed1996

Guidelines for occupational musculoskeletal load as a basis for intervention: a critical review.

Rationalization efforts in industry, both in the Scientific Management tradition and also based on recent rationalization theories, have as one of their main aims to increase the utilization of workers. Clearly, there is a limit to the amount of physical work each employee can perform without developing musculoskeletal disorders. Such limits are generally set by guidelines for acceptable work load. This paper reviews the physical work load concept, the historical development of guidelines, and current guidelines as found in ergonomics textbooks. The focus is on the change in the aim of the guidelines over time: increased productivity, reduced fatigue and finally improved musculoskeletal health. Current guidelines for physical work load mostly emphazise a reduction in the level of work load, while there are few guidelines that consider the repetitiveness and duration of work load. As the guidelines in general only consider one exposure variable, this is a particular problem in rationalization where all three exposure dimensions may be changed simultaneously. Present guidelines are mainly based on laboratory studies aiming to eliminate short-term physiological or psychological responses. These guidelines are clearly inadequate and may be misleading in view of recent research regarding the relationship between physical work load exposure and the development of musculoskeletal complaints at the work place.

Journal Article↗

PubMed1991

A survey and analysis of states' methodologies for deriving drinking water guidelines for chemical contaminants.

Data from a national survey questionnaire regarding the development of guidelines for chemical contaminants in drinking water were collected from all 50 states. Twenty-three states develop at least some of their own guidelines; the other 27 states rely on guidelines previously developed by the U.S. Environmental Protection Agency (USEPA) or by other states. States which derive guidelines generally employ toxicological criteria and risk assessment methodologies developed by the USEPA. Fourteen of the twenty-three states that develop their own guidelines depend on cancer potency factors derived by the USEPA to establish risk-based concentrations for carcinogens. Most of the states develop guidelines based on preventing possible excess cancer risk greater than one in one million. Seventeen of these twenty-three states rely on oral reference doses (RfDs) to derive guidelines for noncarcinogens. Examination and clarification of the states' approaches to guideline derivation reveal that although similar risk assessment techniques are generally employed, differences in assumptions, chemical classifications, and uncertainty factors may lead to variation in resultant guidance levels. Improved communication and coordination between states and the federal government may help reduce the variations and inconsistencies among the states in establishing drinking water guidelines for chemical contaminants.

Carcinogens↗