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).

Effects of Local Guideline Implementation on Costs

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:

  • Implementing surgical care guidelines for patients with gynecologic cancer in one surgical practice improved clinical outcomes, decreased hospital length of stay, decreased costs, and kept patient satisfaction high. A team approach to guideline development and accountability systems accounted for the program's success (Morris et al., 1997).
  • Implementing surgical care guidelines for patients undergoing radical prostatectomy in hospital practice decreased length of stay, while maintaining high scores on patient satisfaction and quality of life (Litwin et al., 1996).
  • Implementing clinical pathways and treatment protocols in one cancer group practice led to greater efficiency (increases in number of patient encounters, decreases in costs) and increased participation in clinical research (Feinberg and Feinberg, 1998).
  • Implementing a clinical practice guideline for endoscopic sinus surgery at an academic medical center led to improved short-term outcomes (i.e., fewer unplanned admissions) and lower costs (Stewart et al., 1997).
  • Implementing critical pathways for cancer care within a managed care organization reduced length of stay and costs for patients treated for respiratory cancer and for those undergoing chest procedures and bowel surgery (Patton and Katterhagen, 1997).

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

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