Clinical practice guideline

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Clinical practice guidelines are defined as "Directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery."[1]

Clinical practice guidelines were initially encouraged by the Institute of Medicine in 1990.[2]

They are becoming increasingly important in healthcare economics, as a means of avoiding waste on ineffective treatment approaches. At the same time, there are concerns that overemphasizing them may limit legitimate physician decisionmaking about the needs of specific patients. Some insurers emphasize their use,[3] needed to go outside them.


Institute of Medicine (IOM) Standards for Trustworthiness[4]

  1. Transparent process
  2. Conflicts of interest
  3. Systematic reviews
  4. Guideline development group composition
  5. Evidence quality and recommendation strength
  6. Articulating recommendations
  7. External review
  8. Updating

Standards for the conduct of clinical practice guidelines are available[5] including recommendations by the Institute of Medicine.[6]

Standards for reporting guidelines are available.[7]

Part of creating a clinical practice guideline is to gather and assess all of the relevant research. This task can be done using a framework such as the GRADE system.[8] Techniques such as decision analysis [9] and nominal group technique[9] may improve the validity of clinical practice guidelines. The methods of guidelines are evolving.[10]

Benefits and disadvantages of guidelines

Medical care guided by evidence-based guidelines may be associated with better outcomes among patients with pneumonia.[11][12]

Disadvantages of guidelines

Guidelines may have trouble with both validity and readability.[13] This trouble may be increasing.[14] Even guidelines that are technically well-done may not be acceptable to clinicians.[15]

A structured comparison of clinical practice guidelines for diabetes mellitus type 2 found variation in guideline quality with the best guideline being produced by the United Kingdom National Institute for Health and Clinical Excellence.[16]

There are proposals to reform the production of guidelines.[17]


Guidelines may not always be based on high quality evidence [18][19] and the quality of evidence used may be decreasing[14].

Two important attributes of a practice guideline are:[20]

  1. Credibility to a range of stakeholders including clinicians, patients, and policy makers.
  2. The developers are accountable for their conclusions by using a process that is open, documented, and reproducible.

Bayesian interpretation of guidelines may help in their interpretation.[21]

Less rigorously developed guidelines may have more aggressive conclusions.[22]

Guidelines may make recommendations that are stronger than the supporting evidence.[23]

Guidelines developed by specialty societies may be of less quality.[24][25]

Because of concerns about the quality and validity of some practice guidelines[26], standards have been developed in both their reporting[27][28] and assessment.[29][30]

Oncology guidelines may have poor methods.[31]

Conflict of interest

Conflict of interest is a common problem with guidelines.[32][33][34]

Oncology guidelines may have conflict-of-interest.[31]

Applicability to individual patients

Guidelines are usually developed for the care of a single disease; consequently, guidelines may direct care that is contrary to the overall well being of a patient with multiple comorbid diseases.[35]

Practice guidelines may not direct the health of a population as efficiently as customizing medical care based on the risk factors that each individual has in a population.[36][37][38]


Guidelines can be very difficult to read which may contribute to lack of impact.[39] For this reason, some are now written with the inverse pyramid structure.[40][41]


Guidelines may loose their clinical relevance as they age and newer research emerges.[42][43] Even 20% of strong recommendations, especially when based on opinion rather than trials, from practice guidelines may be retracted.[44]


The effect of publication

The publication of clinical practice guidelines do not always influence health care[45][30] or take several years to do so.[46] Guidelines published with supporting material may be effective.[47]Balanced against this is that guidelines may be out-of-date after an average of three years.[43]

Other measures to increase effect

Improving outpatient therapy for patients with low risk pneumonia[48]
Intervention(s) Proportion of low-risk patients treated as outpatients Proportion of outpatients receiving all recommended processes of care
Audit and feedback Instruction on using the pneumonia severity index Real-time reminders
Yes No No 38% 25%
Yes Yes No 61% 28%
Yes Yes Yes 62% 61%
Improving the Glycosylated hemoglobin A (Hb A1c)[49][50]
Intervention(s) Mean reduction in Hb A1c
Physicians given list of patients who are uncontrolled Letters sent to patients who are uncontrolled Physicians given time to discuss list with care team
O'Connor PJ et al, 2009[50]
No No No -0.19
Yes No No -0.07
No Yes No -0.12
Yes Yes No -0.11
Stroebel RJ et al, 2002[49]
Yes No No -0.14
Yes No Yes -0.13
Yes Yes Yes -0.25

The more modalities used to implement a guideline, the more impact the guideline will have.[48][51][49]

In addition, a systematic review of organizational interventions to improve the quality of care of diabetes mellitus type 2 suggests that interventions based on complexity science will be more successful.[52]

Finding published clinical practice guidelines

For guidelines published in the United States of America the National Guidelines Clearinghouse republishes many guidelines in a standardized format.

Guidelines can also be located at PubMed by searching for the publication type 'practice guideline'.[53] In addition, the Hedges Team has published a MEDLINE search strategy.[54]


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