CLINICAL PRACTICE GUIDELINE IMPLEMENTATION DEMONSTRATION

临床实践指南源自有效性、结果和 适当性研究是密集研究和政策的重点 美国医疗保健系统内的活动。规模大、资金雄厚 整个系统都在努力开发、测试和完善 适用于各种医疗条件和程序的指南。这个 这些努力对临床实践的最终影响尚不清楚， 但是：关于准则传播过程的信息， 实施和使用很少--以及来自以前努力的证据 改变医生的行为表明，如果没有积极的传播 和执行努力，指导方针可能不会产生太大影响 在医疗实践方面。 这里提出的准则实施示范研究代表了 严格的、大规模的演示和实验评估两个 可选择的准则实施战略。每种策略都是 以行为科学理论和健康服务研究为基础，以及 在之前的研究中，每一个都显示出了相当大的希望 示威游行。这两种选择都是潜在的有效手段 通过指导方针改变临床实践模式。建议数 这项研究的目的是在一项随机试验中测试这些策略，使用12个 6家社区医院的医生小组--环境类似于 其中大部分复杂的医疗服务是在美国提供的。 使用兰德制作的两个全面、可信的实践指南 将检查合适的方法：冠状动脉造影术和 子宫切除术。将评估实施战略的有效性 通过对2400份接受治疗的患者的病历进行显性审查 在准则执行干预前后；其他 将收集有关医院和医生的背景数据 特征和行为。随机分配到干预或 对照小组和其他研究设计特征将确保有效性 和结果的推广性。

Clinical practice guidelines derived from effectiveness, outcomes, and appropriateness research are the focus of intensive research and policy activity within the U.S. health care system. Large-scale, well-funded efforts are underway throughout this system to develop, test and refine guidelines for a wide variety of medical conditions and procedures. The ultimate impact of these efforts on clinical practice remains unknown, however: information concerning processes of guideline dissemination, implementation, and use is scarce -- and evidence from previous efforts to change physician behavior suggests that, absent active dissemination and implementation efforts, guidelines may fail to have much influence on medical practice. The Guideline Implementation Demonstration study proposed here represents a rigorous, large-scale demonstration and experimental evaluation of two alternative guideline implementation strategies. Each strategy is grounded in behavioral science theory and health services research, and each has shown considerable promise in previous studies and demonstrations. Both alternatives represent potentially effective means of changing clinical practice patterns through guidelines. The proposed study aims to test these strategies in a randomized trial using 12 physician groups in 6 community hospitals -- settings similar to those in which the majority of complex medical care is delivered in the U.S. Two comprehensive, credible practice guidelines produced using the RAND appropriateness method will be examined: coronary angiography and hysterectomy. Implementation strategy effectiveness will be evaluated through explicit review of 2400 medical records for patients treated before and after the guideline implementation interventions; additional background data will be collected on hospital and physician characteristics and behaviors. Random assignment to intervention or control groups and other research design features will ensure validity and generalizability of the results.