and evaluation of care. Each of these applications is described below. Although some applications may occur more quickly than others, Figure 4–1 is not meant to imply a linear order to their accomplishment. Rather, the priority conditions can be used for any of these applications as soon as they have been identified.

Synthesize the Evidence Base and Delineate Practice Guidelines

The identification of priority conditions provides a framework for synthesizing the evidence, developing practice guidelines, and delineating best practices for clinical care. There is a significant lag between the discovery of better forms of treatment and their incorporation into actual care. The identification of priority conditions supports a well-thought-out organization of information to improve its accessibility and utility for both patients and health professionals (see Chapter 6). Identification of these conditions can guide the prioritization of issues for analysis and synthesis of evidence, delineation of practice guidelines, and development and application of automated decision support tools. It can also provide direction for stronger dissemination efforts aimed at communicating this information to clinicians and consumers. Even in clinical areas characterized by strong evidence and general consensus on practice, variability in practice suggests that current dissemination efforts could be improved. The Internet offers the opportunity to achieve such improvement by reaching sizable proportions of both consumers and clinicians in a timely manner.

One of the strongest examples of synthesizing the evidence base and applying it to clinical care is offered by the Veterans Health Administration (VHA). The VHA’s Quality Enhancement Research Initiative (QUERI) is a quality improvement program that focuses on eight priority conditions: chronic heart failure, diabetes, HIV/AIDS, ischemic heart disease, mental health (depression and schizophrenia), spinal cord injury, stroke, and substance abuse (Demakis et al., 2000). These conditions were selected on the basis of the number of veterans affected, the burden of illness, and known health risks among the veteran population. Specific conditions were selected as the focus in the belief that quality improvement is most likely to occur when viewed in the context of the overall care of a patient and population, rather than the individual components of care (Demakis and McQueen, 2000).

The process implemented at the VHA involves defining best practices by reviewing currently available information and literature. For some conditions, such as diabetes, a great deal of information is available; for others, the information must be developed by a planning team. Once the evidence has been reviewed and best practice defined, the latter is compared with current practice to identify gaps in performance. Policies, procedures, and programs are then developed to organize care around the best practice, which also guides the evaluation of impact and feedback to enable learning from experience and continuously improving care. Thus, best practice affects how care is delivered, but evaluation



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