What it Means to Follow a Guideline

As society moves toward requiring greater accountability for medical practice, clinical practice guidelines based on expert evaluation of relevant data have received greater attention as a potential tool for measuring quality. However, because using guidelines in quality measurement is relatively new, little exploration has occurred regarding what it means to actually “follow” a guideline. This is particularly concerning in an environment in which adhering to recommendations or not might have consequences for patient referrals or financial incentives.Guidelines are designed to assist the clinician in making appropriate decisions about the patients' care.1 A good guideline provides a range of appropriate options—but only appropriate options—that a clinician can choose among for individual treatment decisions. During guidelines development, available evidence is considered and used as the foundation for recommendations, with high level evidence preferred. When high level evidence is not available, guidelines developers use lower level evidence, including phase II studies and retrospective analysis. Experts evaluate the evidence available at the time and make recommendations expecting that, over time, new data will drive changes in the guidelines.2Guidelines developers consider key decisions that must be made in providing appropriate care. They cannot, however, address every possible situation that might arise. In developing the NCCN Clinical Practice Guidelines in Oncology™, for example, panel members invoke the “5% rule”: if a situation will probably not be encountered in more than 5% of the patient population under consideration, that situation is not addressed in the guidelines. This strategy limits undue complexity and emphasizes that, even...

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Joan S. McClure, MS, is Senior Vice President of Clinical Information and Publications for the NCCN. She is responsible for the NCCN Clinical Practice Guidelines in Oncology™; associated Guidelines for Patients in both English and Spanish; the NCCN Drugs & Biologics Compendium; NCCN Information Technology; and JNCCN; and also serves as an Associate Editor for JNCCN. Ms. McClure previously managed national oncology information programs for patients, health professionals, and the public on contract with the U. S. National Cancer Institute (NCI). She directed investigator and patient recruitment efforts in oncology for a multinational contract research organization, where she also managed the technical and scientific efforts to identify and develop standards for medical and toxicology data for submission to regulatory authorities in the United States, Europe, and Japan.

References

  • 1.

    FieldMJLohrKN(Eds). Clinical Practice Guidelines: Direction for a New Program. Washington, DC: National Academy Press; 1990.

  • 2.

    WinnRWMcClureJS. NCCN Clinical Practice Guidelines in Oncology: a primer for users. J Natl Compr Cancer Netw2003;1:513.

  • 3.

    2006 Oncology Demonstration Project. Medlearn Matters: Information for Medicare Providers. Washington, DC: Centers for Medicare and Medicaid Services; 2006. Available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4219.pdf. Accessed June 29 2006.

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