|Practice Guidelines: A Call to Action
Christina Cruz Dominguez
Steven Dominguez, MD, MPH
Conceptually, practice guidelines are meant to promote "high quality" cost-effective
medical care by outlining which diagnostic tests and treatment strategies are most
likely to aid in the diagnosis of disease and promote favorable patient outcomes.
However, let us not be deceived, a practice guideline is a form of a cost-effective
The federal government in December, 1989, created within the US Department of
Health and Human Services, the Agency for Health Care Policy and Research (AHCPR)
which has been changed to the Agency for Healthcare Research and Quality (AHRQ).
Since 1998, the United States Preventive Services Task Force (USPSTF) is an AHRQ
funded agency that is comprised of experts in the field of preventive medicine. The
AHRQ has as one of its priorities the development of practice guidelines. There were
19 practice guidelines developed until 1996 by the AHCPR. The AHRQ process is
designed to produce practice guidelines that are scientifically and methodologically
based, and which had been reviewed and critiqued by a multidisciplinary panel of
Several basic assumptions underlied the development and promotion of the AHRQ
practice guidelines. These are: 1) medicine is practiced in diverse settings with wide
variation in styles applicable to the same disease process, 2) organizing the
preferred diagnostic and treatment modalities and disseminating the information to
practitioners and the public will curtail the use of unnecessary testing and improve
the quality of medical care delivered, 3) multispecialty panels of experts will promote
genuine practice guidelines which might not occur if left to individual specialty
interests, 4) patients need health care information to successfully access quality
The development of practice guidelines should address the following critical areas:
efficacy, effectiveness, specificity, generalizability, treatment algorithms, cost factors,
malpractice implications, and acceptance. Efficacy is defined as "what is generally
known to be of value." The vast amount of medical knowledge and differing
diagnostic and treatment options preclude a specific detailed account; however, a
general established consensus is necessary. For example, the use of thrombolytics,
anticoagulants, immediate angioplasty, and coronary artery bypass grafting are
generally known to be of value in the treatment of myocardial infarction.
Effectiveness means that which has been shown to provide clinically proven positive
outcomes relative to an alternative; this is typically reported in a scale of performance
figures. For example: drug x is more effective than drug y in terms of onset of action,
lower clinical side effects, and shorter hospital stay.
Specificity in practice guidelines must reflect the generally accepted standards for the
"average complaint." Danger lays in waiting for both the narrow and the overly
generous practice guideline. The narrow practice guideline produces a false step-by-
step recipe for the diagnosis and treatment of the complaint, and the overly
generous practice guideline produces an unfocused approach to the complaint.
The practice guidelines should be generalizable to the population served per setting.
For example: a guideline developed for the evaluation of the acutely syncopal patient
presenting via ambulance to the emergency department will be different than the
work-up of the same patient presenting a week later to the primary care physicians
The implementation of practice guidelines should decrease the cost factors
associated with the wide variation of the practice of medicine. Proponents of practice
guidelines argue that by controlling costs (becoming cost-effective), physicians could
net a greater volume of patients via added managed care contracts, and thus
increase their reimbursement and incomes.
Malpractice liability is a constant concern of the practicing physician. The existence
and applicability of practice guidelines in both patient care and lawsuits is raised
repeatedly by both proponents and adversaries of cost containment “practice
Practice guidelines should be developed in such a manner that they reflect the
generally acceptable diagnostic and treatment options based on the available
scientific and clinical outcome data specific for that complaint. Contrary to the USPSTF
statement that their “recommendations are considered the "gold standard" for clinical
preventive services” (http://www.ahrq.gov/clinic/uspstfab.htm); practice guidelines
should not be written nor interpreted as "Gold Standards" that may confine and
adversely affect patient care and outcomes; flexibility in adhering or changing the
practice guidelines to reflect the patients' condition may prevent decreasing the
"quality" of care and outcomes.
Acceptability of the practice guidelines is a critical factor in the development and
especially the implementation phases. A practice guideline that is too conservative,
scientific, or specific may not be generalizable and hence unacceptable. An
unacceptable practice guideline while unenforceable may non-the-less lead to
compromises in the patient care delivered, poor outcomes, and lawsuits.
In addition to the AHRQ initiatives, many HMO's, insurance companies, and hospital
committees have developed and implemented "practice guidelines" for varying
medical conditions. Some of these practice guidelines genuinely seek to achieve cost
containment through cost-effective, patient outcome strategies, and others have only
cost containment incentives. Patients and physicians alike are typically caught in the
midst of obtaining or practicing quality medicine under the constraints of the patients
reimbursement "practice guidelines." Patients and physicians should acquaint and
involve themselves with the development process of practice guidelines at all levels.
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