Guidelines Have Their Limits

• Practice guidelines
• Neurology
• Physician's practice patterns
• Dementia
• Decision making

Clinical practice guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (1). Many organizations are working diligently to develop guidelines, and a great deal has been written on the process of development, the attributes of an ideal guideline, and the need for evaluation of development processes.

A substantial body of literature focuses on the dissemination and impact of guidelines. Unfortunately, there are many questions about and very few answers as to the best ways of disseminating guidelines and assessing their effect on physician behavior (2). The article by Gifford and colleagues in this issue studies the impact of a well-designed intervention to improve neurologists' adherence to specialty society-endorsed guidelines (3).

Gifford and colleagues' study has many strengths. It was based on social influence theory, in which opinion leaders, who are respected by their peers as authoritative sources of information, are thought to positively influence the adoption of guidelines developed by a national organization. A multifaceted education program was developed by using the principles of evidence-based medicine and adult learning theory. It consisted of a mailed continuing medical education course, a resource manual, and continuing medical education seminars led by an opinion leader, a study investigator, and a representative from the Alzheimer's Association. Outcome measures used surveys plus audits of actual medical records to assess validation of the survey responses.

Although this study had a sound theoretical basis, used a methodology that was proven to be successful in other studies, and was carried out with attention to detail, the intervention's effects on physician behavior were not impressive. There are several possible explanations …