Guideline Recommendations and Results: The Importance of the Linkage

The landscape of medical practice is changing rapidly, and the era of accountability, heralded almost 20 years ago by Relman (1), has undoubtedly arrived. Efforts to codify practice and assess the performance of medical care are proliferating, along with rewards for good practice in the form of a wide array of financial and nonfinancial incentives. These incentives are finding their way into the fabric of the health care system as those who pay for health care strive to bring practice into alignment with evidence.

Clinical practice guidelines—almost 2000 currently listed in the National Guideline Clearinghouse (2)—are the foundation for much of this new accountability. The evidence on which we base practice guidelines, however, is almost always imperfectly suited for direct translation into practice settings. Because clinical decisions in practice commonly must go far beyond the evidence, guideline authors often rely on expert opinion to provide useful advice. Even when evidence from randomized trials is available, study samples and settings are often narrowly defined, which raises questions about their relevance to typical clinical practice. For example, many trials have included few older patients, even for such conditions as heart failure, which affect very high percentages of elderly persons (3). Thus, even as guidelines may represent the best distillation of evidence and expert opinion, we must validate the recommendations.

This issue is particularly important when we …