credibility to information from sources they know and respect (U.S. Congress, 1994). Guidelines with greatest likelihood of success include those with internal development, specific educational intervention, patient-specific reminders at the time of consultation, and a system to hold the provider accountable for adherence (Table 6.5) (Grimshaw and Russell, 1993; Smith and Hillner, 1998). Guidelines that have a lower chance of success are those issued by a national group with no ties to local practitioners, those that rely on publication in a journal to disseminate findings, and those that limit implementation to general reminders about the recommendations. In general, changes in practice are more likely if implementation efforts are more active and intensive, if they involve multiple-rather than single-pronged approaches, and if the efforts are tailored to the specific context and problems addressed by a particular guideline (U.S. Congress, 1994). Clear benchmarks, or targets, for good practice are needed to implement and evaluate guidelines (Schoenbaum et al., 1995).

Some clinical practices are more amenable to change than others. Cancer screening practices, for example, can be increased by using computer and manual reminders, as well as a variety of other administrative mechanisms. Guidelines for the use of x-rays, blood tests, and pharmaceuticals have also been implemented successfully. Interventions to change practice have been less successful for more complex clinical decisions, such as choosing between medical and surgical treatments or managing complex medical problems (U.S. Congress, 1994).

TABLE 6.5

Framework for Analysis of Clinical Practice Guideline Success

Likelihood of Success

Development

Dissemination

Implementation

Accountability

High

Internal

Specific educational intervention

Patient-specific reminder at time of encounter

Practice monitored, feedback given

Above average

Intermediate

Continuing education

Patient-specific feedback

Practice monitored

Below average

External/local

Mailing targeted groups

General feedback

None

Low

National/external

Publication in journal

General feedback

None

 

SOURCE: Grimshaw and Russell, 1993, modified by Smith and Hillner, 1998.

What Evidence is There That Cancer Practice Guidelines Have Been Successful?

There have been a modest number of successful clinical practice guideline efforts, as well as a number of documented failures. In some areas, improvements in guideline compliance have been demonstrated, but often the improvement in practice has not been substantial.

The Community Hospital Oncology Program. The Community Hospital Oncology Program (CHOP) represents an early attempt to improve oncology by disseminating locally developed practice guidelines. From 1982 to 1984, 17 CHOP programs located throughout the country im-



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