With more than 1000 new guidelines produced annually over the past decade, it is impossible for the practicing family physician to determine which ones should be adapted into their clinical practice. The Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association formed the Guideline Advisory Committee (GAC) in 1997 to assess and disseminate guidelines that would improve the quality and utilization of health care services in the province. Over the past 3 years the GAC has developed a strategy to identify important topics, to rank guidelines published on these topics based on the quality of their development, and to reformat guidelines as necessary to make them user-friendly for implementation in clinical practice. The GAC is currently assessing a number of strategies to enhance the dissemination of selected guidelines to improve the quality of care delivered in the province.
Key points for clinicians
A method of selecting, reviewing, and endorsing clinical practice guidelines has been established in the province of Ontario, Canada. Recommended guideline summaries are posted on a Web site with links to full text for easy access by practicing physicians (www.gacguidelines.ca).
Strategies for the successful implementation and impact evaluation of recommended guidelines are currently in development.
Clinical practice guidelines are statements that are systematically developed to assist physisican and patient decisions about appropriate health care for specific clinical circumstances.1 Published guidelines have become widely available through Internet technology; it has been estimated that more than 2500 exist. Most are produced by specific interest groups (eg, national societies and pharmaceutical companies), disseminated by publication in a medical journal or traditional mail, and seldom demonstrate any effect on clinical practice.2 Such a large volume of guidelines creates confusion for clinicians who often do not follow any of them because of the time required to assess their quality.3
With this dilemma in mind, the GAC was formed with members representing the Ontario Medical Association (OMA), the Ministry of Health and Long-Term Care (MOHLTC) in the province of Ontario, and one ex-officio member of the Institute for Clinical Evaluative Sciences (ICES). The GAC determined its first priority was to identify the best-quality guidelines available for clinicians on selected topics and to then promote their dissemination across the province. The purpose of our paper is to describe the methods that have been developed over the last 3 years to identify high-quality guidelines and some of the strategies being proposed for their dissemination, implementation, and evaluation. We also identify the best-quality guidelines for 10 common conditions.
Methods to assess the development of clinical practice guidelines
Using a number of parameters, the GAC initially produced a grid as an assessment tool to identify priority areas for guideline review. Table 1 shows the basic grid incorporating provincial utilization and cost data, outcomes research, feedback from clinicians or health care organizations, and a previously published list of common and important problems in family practice.4 Feedback from the OMA sections indicated considerable confusion resulting from conflicting advice in specific areas as to appropriate practice (eg, screening for osteoporosis and diabetes). Utilization data from the MOHLTC demonstrated that the use of numerous procedures had rapidly increased over previous years; for example, diagnostic ultrasound utilization increased 65% in 1998. Practicing physicians also identified areas where there was a need for guidelines to be developed because of a lack of evidence or unknown best practice. The committee took all these factors into account when producing a list of priority topics for guideline assessment Table 2.
Guideline Assessment and Recommendation
Once a topic was chosen for assessment, a literature search was conducted by University of Toronto librarians to find all guidelines published in English over the past 10 years on that specific topic. The search strategy included databases such as MEDLINE and HealthStar, and guideline Web sites such as the National Guideline Clearinghouse and the Canadian Medical Association’s Clinical Practice Guideline Infobase. Copies of all guidelines identified in the search were then obtained. A survey of associations and interest groups in Ontario was also made to determine whether there were any unpublished guidelines that we had not identified in this process.
Initially, members of the committee carried out a literature search to determine if there were any publications about scoring the quality of the process used to produce the guidelines. Our search found some processes, but none that directly suited our needs. As a result, the GAC embarked on the development of a guideline-scoring instrument. After a year of work we realized that it would likely take 2 to 3 more years to adequately validate the instrument, and thus a decision was made to adopt the Appraisal Instrument for Clinical Guidelines5 (available at: www.sghms.ac.uk/phs/hceu/form.htm) to help determine quality guidelines in each clinical area, supplemented by the tool developed by the committee. The Appraisal Instrument consists of 37 items addressing 3 dimensions Table 3. The classification system the committee is using to choose top-scoring guidelines after appraisal is as follows. An excellent guideline is one in which the majority of the dimensions (rigor of development, context and content, application) are well addressed by the guideline producers with minimal omission. The evidence is linked to the major recommendations, and the development process is robust. These types of guidelines are highly recommended.