Evaluating guidelines: An important step in improving cancer care

Freestanding patient management guidelines have had a minimal impact on physician behavior. Their passive distribution and implementation have proven to be no more effective than conventional medical education programs. Evaluating compliance with guidelines, providing feedback to physicians, and assessing the impact on clinical, social, and economic outcomes is critical to optimal use of the guidelines. The acceptance and implementation of patient management guidelines will depend on the probable benefits and outcomes. The orderly structure and appeal of the guidelines, coupled with claims regarding their ease of application, cannot replace a substantive evaluation. Methods for evaluating guidelines may include (1) conducting patient and physician surveys, (2) measuring general compliance to recommendations on major decision points, (3) abstracting information from clinical records, (4) using payer data to determine resource use, and (5) using cancer registry data to follow outcomes. The application of guideline recommendations without an evaluation of their influence on patient outcomes provides minimal benefit at an extremely high cost. Information from evaluations must be fed back to practitioners, and particularly to local "opinion leaders." The goal of guideline implementation should be to improve practice patterns and ultimately patient outcomes. Physicians should be certain that the guidelines will improve the care of their patients, and they should also receive the administrative support they need to ease guideline application. Health maintenance organizations have used financial incentives and disincentives to encourage compliance with guidelines, with some degree of success. The success of clinical management guidelines is a complex effort that varies greatly depending on local conditions. Improvements in guideline compliance will require the use of multiple interventions tailored to the local practice environment.