CONTEXT, PHILOSOPHIES, AND STRATEGIES

The context in which guidelines are to be implemented is important, involving as it does a cultural shift in American society. The nation is moving away from a tradition of substantial deference to professional judgment and discretion toward more structured support and accountability for such judgment. This shift takes visible and sometimes controversial form when guidelines for clinical practice move from the development to the application stage, especially when application is backed by formal organizational structures and procedures and by forceful incentives.

The ways in which practice guidelines can and do operate as instruments for professional support and accountability are affected by the dynamics of a health care system that is changing and evolving, very often with no particular regard for practice guidelines. These complex, ongoing changes involve such fundamental matters as

  • how medical care is organized and monitored

  • how health benefits are provided to individuals and groups

  • how practitioners and providers are paid

  • how patient preferences are treated

  • how information is recorded, manipulated, and retrieved.

These changes may both support and undermine practice guidelines. Although policy makers may try to anticipate and avoid mismatched incentives, those managing the health care system inevitably will be left to deal with inconsistencies or conflicts, such as payment systems that reward overuse of care and guidelines that are intended to discourage such excess.

In addition, guidelines are affected by the conduct of clinical research—its scope, priorities, and methods. Clinical and health services researchers can play an important role in making guidelines more applicable to operating environments. In particular, if researchers pay more attention than they have in the past to testing the effectiveness of procedures and patient management strategies in real settings as well as in highly controlled clinical trials, developers of guidelines are likely to have a knowledge base with greater practical relevance to practitioners and others. In turn, the greater the number of practitioners and institutions that adopt the outcomes management tools developed by health services researchers, the greater the body of information that will be available to evaluate and revise guidelines to make them still more useful in achieving desired outcomes. Overall, the influence on behavior of the varied and complex operational environments in which guidelines are to be applied cannot be stressed too much.

Practitioner knowledge of guidelines and acceptance of their validity are key conditions for their successful application, but acceptance is not equivalent to change. Thus, as a practical matter, it may be better strategi-



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