Clinical Practice Guidelines/Pathways

Well-designed clinical practice guidelines should recognize and filter strong and weak evidence, expert opinion, and conflicting information from many sources in a way that makes the information useful to a specific audience. Good guidelines should acknowledge that their uses may differ from user to user, but no matter how the guideline is applied, the use should not conflict with valid scientific evidence. Wise choice and use of authoritative guidelines eliminate for clinicians the improbable task of sorting through the information maelstrom in which we now exist.

Practice guidelines are developed by experts acting on behalf of professional societies, guideline companies, health plans, medical organizations, pharmaceutical manufacturers, disease management vendors, government agencies at all levels from CMS to local health departments, research organizations, purchasers of health care services, advocates, and consumer groups. These policies contribute to decisions about every aspect of the delivery of health care from timeliness of the delivery of preventive health services to legislation regarding malpractice. It is important to identify the validity of the recommendation, the end user, the target population, and the desired result of proper application of the guideline.

The selection process for choosing one set of guidelines over another may lead a physician in a group practice to choose asthma management guidelines developed by colleagues who practice in the specialty of allergy and immunology. Pediatricians in the same group may choose the same guideline produced by the Academy of Pediatrics (2002). Many guideline developers have selected physicians as the audience for their materials.

Clinicians may have been the principal target for the use of guidelines in the treatment of their patients. However, clinical guidelines have a number of useful applications outside of the direct care of a patient. David Eddy (1990–1991) described the uses of practice policies in terms of flexibility of their application. The most flexible application of clinical guidelines is to advise practitioners about the choices available to them during an episode of direct patient care. Clinicians may consider this cookbook medicine unless they realize that the choice and consequence remain theirs. No matter how specific a guideline may be, no matter how brief the episode of care to which it applies, the choices offered only apply to a segment of the target population. It is the practitioner's skill that determines to whom, and at what time, a clinical recommendation makes sense. Thinking in these terms makes physician clinical guidelines the most flexible use to which these decision support tools may be applied. Although compliance with guidelines is expected to affect outcomes, level of compliance is difficult to measure. Most measures of compliance are related to intermediate outcomes. For example, pediatric immunization rates, mammography screening rates, and other measures of steps in the care process are used to estimate compliance. Measured thus, physician performance varies substantially.

Clinical pathways, which are more structured than clinical guidelines, are used principally by nonphysician practitioners to deliver timely care over a set period of time and require higher levels of compliance than clinical guidelines. They rely on the same evidence but generally require a deliberate justification for variation, often in writing in the medical record. A pathway should be considered a management tool for applying a clinical guideline (see Kelly & Bernard, 1997).

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