Audet A M, Greenfield S, Field M
New England Medical Center, Boston, Massachusetts.
Ann Intern Med. 1990 Nov 1;113(9):709-14. doi: 10.7326/0003-4819-113-9-709.
To examine the state of the art in the field of medical practice guidelines, to identify limitations, and to suggest future directions.
Informal descriptive survey using a questionnaire administered by telephone, supplemented by comments, by opinions, and by examples solicited from the participating organizations.
Eight prominent organizations representing prototypic approaches to guideline development; these organizations included three medical societies, two health care organizations, two insurers, and one private health benefits management company.
Improving the quality of medical care was a stated goal of all eight surveyed organizations. However, their objectives have not been stated in operational terms, reflecting the lesser emphasis placed on methods and means for both implementing guidelines and evaluating their impact on health practices and outcomes. In contrast, several systematic methods for developing guidelines exist. They differ in the stress placed on formal literature reviews, reliance on local as opposed to national experts, and formal methods of group judgment, but no evidence exists on which approaches produce sounder and more usable guidelines.
Guidelines are being vigorously promoted as a means to improve the effectiveness of the health care system. Current initiatives show both strengths and weaknesses. In particular, the attention now paid to the development of guidelines needs to be matched by attention to implementation strategies and to the scientific evaluation of their effectiveness in real clinical settings. Also, more agreement is needed on acceptable methods for developing guidelines, assessing their content, and evaluating their impact on professional behavior, patient outcomes, and health care costs. Fortunately, several initiatives to bring greater order and quality to this field are under way.
审视医学实践指南领域的现有状况，识别局限性，并提出未来发展方向。
采用通过电话进行问卷调查的非正式描述性调查，并辅以参与组织提供的评论、意见和实例。
代表指南制定典型方法的八个著名组织；这些组织包括三个医学协会、两个医疗保健组织、两个保险公司和一个私人健康福利管理公司。
提高医疗质量是所有八个接受调查组织宣称的目标。然而，它们的目标并未以可操作的方式表述，这反映出对实施指南以及评估其对健康实践和结果影响的方法和手段的重视程度较低。相比之下，存在几种制定指南的系统方法。它们在对正式文献综述的重视程度、对本地专家而非国家专家的依赖程度以及群体判断的正式方法等方面存在差异，但尚无证据表明哪种方法能产生更合理、更实用的指南。
指南作为提高医疗保健系统有效性的一种手段正在大力推广。当前的举措既有优势也有不足。特别是，目前对指南制定的关注需要与对实施策略以及在实际临床环境中对其有效性的科学评估的关注相匹配。此外，在制定指南、评估其内容以及评估其对专业行为、患者结局和医疗保健成本的影响的可接受方法上，还需要更多的共识。幸运的是，目前正在开展多项举措，以使该领域更加规范和优质。
