Durieux P, Ravaud P
Assistance Publique-Hôpitaux de Paris, France.
Int J Qual Health Care. 1997 Jun;9(3):215-9. doi: 10.1093/intqhc/9.3.215.
The objectives of this study are: to present the history of the development of clinical guidelines in France. to present the implementation of a program of clinical guidelines in Assistance Publique-Hôpitaux de Paris (AP-HP), the regional public hospital system of the Paris metropolitan area, and to discuss the lessons learned from this program, which provide a basis for a better policy of guidelines at a national level.
The objective of the AP-HP program is to promote the appropriate use of clinical guidelines and to evaluate their impact on quality of care and/or costs. Experiments such as controlled trials are used to test the effectiveness of some implementation strategies, to verify that guidelines do improve the process of care and to improve physician compliance with clinical guidelines. Guidelines are developed in a context of budget constraint, and the general aim of the program is to promote the more efficient use of available health resources.
In a context of health care inflation, the desire of public authorities is to use guidelines as a tool for cost control strategy, either for ambulatory care or for hospitals. AP-HP experience shows that it is very difficult to develop a national program of clinical guidelines and to implement it in every hospital, as was done in France (but not clearly evaluated) in ambulatory care (under the name 'references médicales'). Guidelines need to be locally adapted, and the best implementation strategies depend on local resources, for example the existence of a pertinent information system. The role of financial incentives is present in French policies, and the role of the drug industry needs to be evaluated.
本研究的目标如下：介绍法国临床指南的发展历程；介绍巴黎地区公立医院系统（AP-HP）中临床指南项目的实施情况，并讨论从该项目中吸取的经验教训，这些经验教训为在国家层面制定更好的指南政策提供了依据。
AP-HP项目的目标是促进临床指南的合理使用，并评估其对医疗质量和/或成本的影响。采用对照试验等实验来测试某些实施策略的有效性，验证指南确实能改善医疗过程，并提高医生对临床指南的依从性。指南是在预算受限的背景下制定的，该项目的总体目标是促进对现有卫生资源的更有效利用。
在医疗保健费用上涨的背景下，公共当局希望将指南作为成本控制策略的工具，无论是用于门诊护理还是医院。AP-HP的经验表明，制定一项全国性的临床指南项目并在每家医院实施是非常困难的，就像法国在门诊护理中（以“医学参考”之名）所做的那样（但未进行明确评估）。指南需要因地制宜，最佳实施策略取决于当地资源，例如是否存在相关的信息系统。财政激励措施在法国政策中发挥着作用，制药行业的作用也需要评估。
