the reliance on peer pressure to change practice behavior (Ray-Coquard et al., 1997). The studies lacked a concurrent control group that was not exposed to the guideline intervention, so it is unclear whether improvements were due to the guideline program or to a generally increased awareness in the medical community.
Scotland. As part of its national health plan, Scotland has initiated comprehensive efforts to improve cancer care. On a national basis, it has limited reimbursement for cancer services to practitioners who agree to use evidence-based guidelines and submit their results to external scrutiny. Full results of the first three years of this program will be available in 1999 (Smith et al., 1998).
Whether implementing guidelines increases or decreases costs depends on the medical interventions involved. Guidelines aimed at currently overused services will likely reduce some spending, whereas those aimed at underused services could increase spending. Some guidelines might shift spending from inappropriate to more appropriate care, leading to better value but not necessarily lower costs (IOM, 1992). Although the intention of guidelines is usually to improve care, an added benefit may be increased efficiency and cost savings. There are several anecdotal accounts of cost savings associated with local implementation of practice guidelines, often with attendant improvements in care:
In summary, several organizations have developed oncology practice guidelines to promote treatment that conforms to the best medical evidence available. Guidelines for many aspects of cancer care are not available, in part because the evidence base upon which to judge best practice does not exist. The oncology guidelines that have been put into practice have not been uniformly successful in changing physician behavior or clinical outcomes. Aspects of guideline development and