Marilyn J. Field and Kathleen N. Lohr; eds. 426 pages. Washington, D.C.: National Academy Press; 1992. $34.95.

Practice guidelines are a fact of life. They increasingly influence the work of practitioners and the thinking of patients, payers, researchers, and policymakers. Further, they are variably viewed with great expectations or frustrations by all of these groups. This book is intended to offer the first balanced view of guidelines—their strengths and limitations and how they can be used more effectively to benefit health care.

The book is the product of an Expert Committee appointed by the Institute of Medicine and its staff. Over the past 2 years they completed a comprehensive examination of guidelines. The examination was based on commissioned papers, public hearings, site visits, focus interviews, and liaison activities with major organizations involved in the development, use, and evaluation of practice guidelines.

The editors have included a thorough description of the history of clinical guidelines, how they have been developed, and how they have been implemented. Case studies of guideline implementations and inclusion of an instrument for assessing clinical practice guidelines add to the practical value of the monograph.

Field and Lohr conclude that guidelines are gaining credibility. Policymakers have endorsed them, funding is increasing, and how-to-do-it conferences and products are multiplying. The major problems the editors see with the guidelines movement are lack of quality control for both national and local efforts and the limited evaluations of the effect of practice guidelines. They recommend that every set of guidelines should be accompanied by a statement of the strength of the evidence and expert judgment behind the guidelines; that guidelines should include projections of the relevant health and cost outcomes of alternative courses of care; that they should explicitly address both shared decision making with patients and informed consent; and that an assessment organization should be established to lead practitioners, patients, and others to better guidelines.

It is difficult to argue with the editors' conclusion that "Good guidelines will be welcomed by physicians and other health care professionals". However, fundamental problems will continue to challenge those who attempt to follow the authors' recommendations for developing and implementing good clinical guidelines. Although these problems are acknowledged in the monograph, they pose dilemmas that make them especially intractable: 1) Many physicians resist guidelines as a potential threat to the most fundamental element of professional autonomy; 2) guidelines are promoted to contain costs and improve quality, which are often incompatible objectives; and 3) the information needed to establish the effect of guidelines and the relevant health and cost outcomes of alternative courses of care is lacking for many important conditions and is unlikely to be produced in the foreseeable future.

In sum, this monograph is important reading for informed practitioners and other health professionals. It provides a glimpse of the future with guidelines, whether we like that future or not, and suggests some ways to make it more palatable for all.