Regular articleStatus of practice guidelines in the United States: CDC guidelines as an example
Introduction
Over the past few decades, two movements have had an important impact on how patient care is delivered. First, as early as the 1970s and increasingly in recent decades, variations and inequities in clinical care for a variety of health conditions such as acute myocardial infarction, cardiac surgery, use of diagnostic procedures, and tonsillectomy, have been noted. Such variations are concerning because they have been associated with factors unrelated to the need for care, factors such as geography, socioeconomic status, ethnicity, or gender [1], [2], [3], [4], [5]. Second, the mandate to mediate escalating costs of health care has resulted in increased motivation among clinicians and policy-makers to identify those practices which result in positive patient outcomes and those practices which cannot be justified because of insufficient evidence of either cost saving or patient benefit [6]. These two factors—recognition of inappropriate variations in patient care and of the need to base clinical practice on outcomes and evidence—have resulted in national efforts to set standards for care and to focus on quality and cost effectiveness.
Clinical practice guidelines offer one mechanism to improve equity and quality in patient care. In 1989, The Agency for Health Care Policy and Research (now Agency for Healthcare Quality and Research, AHRQ) was established to “enhance the quality, appropriateness and effectiveness of health care services and access to these services.” One of their initial activities was to produce a series of 19 clinical practice guidelines (http://www.ahrq.gov/clinic/cpgonline.htm). The Agency also commissioned The Institute of Medicine (IOM) to examine and make recommendations for development, dissemination and implementation of practice guidelines. The resulting two publications have served as the blueprint for rigorous and high quality practice guidelines [7], [8]. The IOM defined practice guidelines as “systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances” [8]. In 1996, AHRQ ceased developing guidelines but established The National Guideline Clearinghouse (http://www.guideline.gov/body home nf.asp?view=home), which now includes >1000 practice guidelines that meet specific quality criteria and are submitted by qualified groups such as other governmental and professional organizations. Currently, many professional organizations in health care are engaged in developing, adapting, and/or implementing evidence-based practice guidelines. In light of this emerging focus on practice guidelines as a mechanism to improve the quality, equity, and efficiency of patient care, the purposes of this article are to briefly review research related to their adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example.
Section snippets
Studies assessing the adoption and impact of guidelines
Research to date on national practice guidelines has focused primarily on two areas: the extent to which guidelines are accepted and implemented by clinicians (i.e., diffusion and adoption), and their impact on processes and outcomes of patient care. While a number of studies have demonstrated that guideline adherence or attitudes regarding practice guidelines is poor, particularly among physicians [9], [10], [11], [12], other studies have demonstrated improvements in practice [13]. For
CDC guidelines as an example
In 1981, the Centers for Disease Control and prevention (CDC) published a manual, “Guidelines for the Prevention and Control of Nosocomial Infections,” containing nine clinical guidelines for infection prevention and control handwashing [40]. The publication and widespread dissemination of these guidelines revolutionized practice because it was the first time that a federal agency had gathered recommended, evidence-based standards of practice to prevent infections into a single document.
New CDC hand hygiene guideline for health care settings
The first national hand hygiene guideline was published by CDC in 1981 [40]. By the 1990s, the guideline had become outdated, but the CDC, citing fiscal constraints, halted their guideline writing and updating process in the mid-1980s. Therefore, APIC, the professional organization comprising about 12,000 professionals in infection prevention and control, took on the task of guideline development. Their first guideline, published in 1988 and revised in 1995, was on hand hygiene [44], [45]. In
Conceptual underpinnings
While the IOM, AHRQ, and other agencies have published criteria for guideline development and quality, there is less information or guidance for assessing the clinical impact of guidelines. For example, the IOM text on clinical practice guidelines [8] devotes only three pages to assessment of impact. Similarly, in 1996 CDC published a document on improving the quality of guidelines. Even though this document describes in detail the entire development process, including needs assessment,
Recommendations for assessing patient outcomes and costs of guidelines
Guideline development requires significant resources; the average time to prepare a HICPAC guideline, for example, is about 2 years and involves dozens of experts. Additional resources are required for disseminating and implementing guidelines, and because guidelines become outdated within a few years [48], there is additional cost for updating them on a regular basis.
Despite this national movement toward standardization of evidence-based practice, the clinical impact and patient outcomes
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Strategies for developing evidence-based clinical practice guidelines to foster implementation into dental practice
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2012, Journal of the American Dental AssociationPre-operative skin preparation practices: Results of the 2007 French national assessment
2012, Journal of Hospital InfectionCitation Excerpt :This study confirms the fundamental importance of providing patients with information about compliance, together with instructions about pre-operative showering. Very few studies have evaluated compliance with guidelines for reducing SSI rates.25–28 In a questionnaire-based survey conducted in Alberta, Canada, 23% of 230 surgeons questioned reported that they recommend pre-operative bathing to their patients, and 60% of these surgeons recommend the use of an antiseptic soap.26
Revisiting the ASPAN Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia
2010, Journal of Perianesthesia NursingHand hygiene among general practice dentists: A survey of knowledge, attitudes and practices
2008, Journal of the American Dental AssociationCitation Excerpt :In contrast to the barriers expressed by other health care professionals, most GPDs reported that they were not too busy for HH, that they often saw patients with infections, that they were at considerable risk of acquiring infection, and that they had access to the requisite supplies to use for following the CDC HH guideline. Other health care professionals have reported for years that these types of barriers are deterrents to HH and to adhering to practice guidelines.15–18 On the other hand, 84 percent of subjects in our survey stated that they agree or strongly agree that they are comfortable with their current HH practices, regardless of guidelines.
Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates
2007, American Journal of Infection Control