Appraising clinical guidelines: towards a "which" guide for purchasers.

Editorial Appraising clinical guidelines: towards a "Which" guide for purchasers All health care services are attempting to control escalating costs in the face of increasing patient needs, expectations, and healthcare interventions. In the United Kingdom the government has responded in two ways: by introducing a competitive health market to provide incentives for efficiency and an emphasis on providing only those services that have been shown to be clinically effective. The latter approach has concentrated on changing professional behaviour through the introduction of a national audit programme' and a research and development strategy.2 Clinical guidelines are proposed as the logical link between these initiatives, with purchasers being encouraged to include evidence based guidelines in their contracts as a method of increasing clinical effectiveness.3 Simply put, the research and development initiative will define appropriate practice, which will be translated into statements of good care (guidelines), and clinical audit will monitor adherence to the guidelines.4 The potential benefits are enormous: an increase in appropriate practice and hence reduced morbidity and mortality; improved efficiency by controlling professional excess; and cost containment by targeting finite resources on effective interventions. Hurdles to implementation However, like all policies attempting to alter professional practice, implementation is proving difficult. The medical profession values clinical freedom and has been suspicious of guidelines. If clinical practice is now to be explicitly linked by guidelines to managerial processes, reassurance is needed that those guidelines will acheive their intended outcome. But how can the quality of guidelines be assessed? The increasing number of local' and national' guidelines available means that purchasers and providers may benefit from a "Which" style report with guidelines appraised against redefined desirable criteria. Is it possible to develop such guidance? Assessing the validity of guidelines The essential prerequisite for improved quality of care is that a guideline is valid. In this context validity means that adherence to the guideline will increase the probability of bringing about the expected health outcome at the expected cost. Guidelines are likely to be more valid if they are based on the results of systematic reviews of the evidence, if they have been developed by national multidisciplinary groups representing the interests of key stakeholders, and if the recommendations are explicitly linked to evidence. Appraising the validity of guidelines depends on the availability of the documentation on their development. A recent pilot study appraised several guidelines published in the United Kingdom against a modified version …