Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways.
OBJECTIVE
We describe the impact of clinical practice guidelines (CPGs) on improvement in oncology treatment processes or outcomes.


METHODS
We performed a comprehensive search of the literature from 1966 to the present and a directed review of the literature.


RESULTS
Improvements have been demonstrated in compliance with evidence-based guidelines or evidence-based medicine, and in short-term length of stay, complication rates, and financial outcomes. The data suggest that patient satisfaction can be maintained despite a shorter length of stay. There has been one example of province-wide improvement in disease-free and overall survival of breast cancer patients coincident with the adoption of CPGS: The components of successful guidelines can be summarized as follows: (1) development is based on evidence, with the guideline formulated by key physicians in the group; (2) the guidelines are disseminated to all affected health care professionals for critique; (3) implementation includes direct feedback on performance to physicians or general feedback on system performance; and (4) there is accountability for performance according to the guidelines. This accountability can consist of voluntary peer pressure to conform to evidence-based medicine, and it does not require a financial reward or penalty.


CONCLUSIONS
Some attempts to improve practice have been moderately successful in achievement of reduced health care costs, reduced hospital length of stay, and possibly improved outcomes. Other methods that are still in use have been demonstrated to have little effect. Programs that have not succeeded have relied on voluntary change in practice behavior without incentives to change or have had no accountability component. Further research is needed to assess how guidelines are enacted in organizations other than those demonstrably committed to improvement, ways to improve compliance of health care providers who are not committed to change, and methods to improve accountability.
Smith
T J
TJ
Massey Cancer Center, Division of Hematology/Oncology, Department of Medicine, Medical College of Virginia at Virginia Commonwealth University, Richmond, VA 23298-0230, USA. tsmith@hsc.vcu.edu
Hillner
B E
BE
D019091:Critical Pathways; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006801:Humans; D007902:Length of Stay; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care