also suggests courts will be more likely to adopt guidelines that are trustworthy and urges them, given reliance on CPGs, to use those deemed trustworthy when available.

INTRODUCTION

Clinical practice guidelines (CPGs) draw on synthesized research findings to set forth recommendations for state-of-the-art care. Trustworthy CPGs are critical to improving quality of care, but many CPGs are not developed for ready use by clinicians. They are typically lengthy documents of written prose with graphical displays (e.g., decision trees or flow charts) making them difficult for clinical use at the point of care delivery. Furthermore, recommendations from CPGs must be applied to patient specific data to be useful, and often, data required for a given guideline either are not available or require too much time to ascertain in a useful form during a typical patient encounter (Mansouri and Lockyer, 2007). Passive dissemination (e.g., distribution) of CPGs has little effect on practitioner behaviors and thus, active implementation (e.g., opinion leaders) efforts are required.

Even with the exponential growth in publicly available CPGs (NGC, 2010), easy access to high quality, timely CPGs is out of reach for many clinicians. Large gaps remain between recommended care and that delivered to patients. A 2003 study by McGlynn et al. of adults living in 12 metropolitan areas of the United States found participants received recommended care 54.9 percent of the time. The proportion of those receiving recommended care varied only slightly among adults in need of preventive care (54.9 percent), acute care (53.5 percent) and care for chronic conditions (56.1 percent). Yet, when McGlynn et al. (2003) inspected particular medical conditions, they noticed a substantial difference in received recommended care, ranging from 10.5 percent for alcohol dependence to 78.7 percent for senile cataract. In an observational study of 10 Dutch guidelines, Grol et al. concluded that general practitioners followed guideline recommendations in only 61 percent of relevant situations (Grol et al., 1998). Furthermore, in an analysis of 41 studies of the implementation of mental health CPGs—including depression, schizophrenia, and addiction—Bauer found that physicians adhered to guidelines only 27 percent of the time in both cross-sectional and pre-post studies and 67 percent of the time in controlled trials (Bauer, 2002; Francke et al., 2008). Of course, not all quality measures are valid and reliable, nor should all CPGs necessarily be adhered to; how-



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