The use of clinical guidelines to improve medical practice: main issues in the United States

The use of clinical guidelines has become a key issue in the US health care system. In contrast to European systems, where such initiatives usually are controlled by one administrative agency, in the US there is a pluralistic approach and many kinds of guidelines coexist, initiated by health professions, managed care organizations, state or federal agencies, hospitals, and insurers. This paper reviews the main trends, indicating that guidelines will play an increasingly prominent role: use of institution-based guidelines vs national, professional, or state-based guidelines; use of more decision-support systems made possible by computerization and changes in cost containment strategies. Combining quality of care objectives with the business objectives of institutions increases the likelihood of a wider adoption by physicians. Several issues, such as the legal implications or the conflict of objectives, illustrate limits in the use of such standards to judge individual cases; however, most recent developments tend to reconcile individual decisions and what is known from probabilities on representative samples. By bringing such information into the decision process between physician and patient, the use of guidelines challenges the traditional asymmetry of information between professionals and patients. In a context of increasing health care costs, clinical guidelines represent a very useful tool for debating rationing issues and standard benefit packages, in order to make the system more equitable. Evaluations of the effectiveness of clinical guidelines on performance are contradictory, but when rigorous evaluations exist, clinical guidelines are found to be effective. The amount of improvement, however, may vary considerably.