argued that the guidelines in use do not adequately address the needs of clinicians, many of whom contract with multiple plans that have different and often contradictory guidelines. Consequently, it was recognized that it may be difficult to change guidelines or implement new ones because effective change comes from the ground up and would need to overcome both psychosocial and organizational barriers. Nevertheless, initiatives to standardize clinical practice guidelines have involved successful collaborations among providers, mechanisms to standardize guidelines across plans, involvement and comments from physicians, and financial and other incentives from major purchasers. Opinion leaders and administrative champions play vital roles in implementing new guidelines.

Guidelines may be less of a problem in infectious diseases than in other subspecialties, as shown by the success of one health maintenance organization in achieving a 40 percent reduction in neonatal Group B streptococcus infections. Managed care organizations offer a number of advantages for evaluating this kind of initiative, including patient recruitment, systemwide implementation and monitoring, and a computerized database. Industry and professional organizations can also play an important role in developing and disseminating new guidelines.

The adoption of clinical practice guidelines may be more easily accomplished for the treatment of emerging infectious diseases than for other subspecialties, in part because the label "emerging" conveys a need for the development and adoption of new guidelines. Even here, however, guidelines should be flexible and dynamic, allowing treatment to change in response to comments on compliance and results. In addition, there may be a need to reassess these data on a regular basis and revise the guidelines as required.



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