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Clinical practice guidelines and healthcare decisions: credibility gaps and unfulfilled promises?

Nature Clinical Practice Oncology volume 2, pages 480–481 (2005)Cite this article

As clinical practice guidelines (CPG) development has gained momentum, so has skepticism about their effectiveness. Improvements in CPG development methods are creating better tools for decision making, but are they having the desired impact? There are concerns about the gap between actual practice and what guidelines recommend. Gaps exist, both at the clinical and policy levels. At the clinical level, there is some evidence that CPGs influence practice, but their effects on practice patterns and outcomes are modest.1 This has led some to question their utility and even cost-effectiveness as healthcare interventions.2,3 Despite the greater investment in CPGs, and their increased rigor, which ensures that recommendations are valid and evidence-based, uptake of CPGs is lower than expected. In response, the focus is shifting from 'getting the evidence straight' to 'research transfer'—identifying reasons for the gap between evidence and clinical practice—and designing interventions to address the gap.

To be useful, CPGs need to inform the clinician about appropriate practice. Recommendations can be made more accessible within a clinical environment by improving the format or mode of presentation. They should be better contextualized, so that recommendations can be fitted to specific local circumstances, with sufficient flexibility to allow legitimate differences in interpretation. They should also be made more sensitive to the social culture of medical practice, by fostering a sense of ownership and accountability in those intended to use them, resulting from participatory processes.4,5 Improvement in the uptake of CPGs is being actively pursued by different groups. The contrast between the extremely rigorous evidence-based CPGs produced by Cancer Care Ontario6 and the more accessible expert consensus algorithms of the National Comprehensive Cancer Network (NCCN)7 highlight different philosophical approaches to producing effective guidelines. Recent innovative processes for CPG adaptation are intended to address issues of local buy-in within local practice contexts.4 The tools offered by the US Guideline Clearinghouse8 allow users to contrast recommendations on the same topic from different CPGs, thus providing more opportunity for considering local contexts and circumstances. Finally, there is growing awareness of the potential benefits of adopting from the business community the 'communities of practice' concept.9

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  1. Director of the Tom Baker Cancer Centre and Head of the Department of Oncology at the University of Calgary, Calgary, Alberta, Canada

    George P Browman

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Browman, G. Clinical practice guidelines and healthcare decisions: credibility gaps and unfulfilled promises?. Nat Rev Clin Oncol 2, 480–481 (2005). https://doi.org/10.1038/ncponc0286

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