Scott Weingarten

Interventions used in disease management programmes for patients with chronic illness—which ones work? Meta›analysis of published reports

Abstract Objective: To systematically evaluate the published evidence regarding the characteristics and effectiveness of disease management programmes. Design: Meta-analysis. Data sources:Computerised databases for English language articles during 1987-2001. Study selection: 102 articles evaluating 118 disease management programmes. Main outcome measures: Pooled effect sizes calculated with a random effects model. Results: Patient education was the most commonly used intervention (92/118 programmes), followed by education of healthcare providers (47/118) and provider feedback (32/118). Most programmes (70/118) used more than one intervention. Provider education, feedback, and reminders were associated with significant improvements in provider adherence to guidelines (effect sizes (95% confidence intervals) 0.44 (0.19 to 0.68), 0.61 (0.28 to 0.93), and 0.52 (0.35 to 0.69) respectively) and with significant improvements in patient disease control (effect sizes 0.35 (0.19 to 0.51), 0.17 (0.10 to 0.25), and 0.22 (0.1 to 0.37) respectively). Patient education, reminders, and financial incentives were all associated with improvements in patient disease control (effect sizes 0.24 (0.07 to 0.40), 0.27 (0.17 to 0.36), and 0.40 (0.26 to 0.54) respectively). Conclusions: All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

The Relation between Systematic Reviews and Practice Guidelines

Systemic Review Series Series Editors: Cynthia Mulrow, MD, MSc Deborah Cook, MD, MSc Historically, implicit clinical policies rested primarily with individual practitioners, protected under the rubric of the art of medicine and modulated by knowledge, experience, and heuristics [1]. Dissemination of information through peer-reviewed publications and traditional continuing medical education represent two major, albeit somewhat passive and indirect, attempts to inform clinical practice. The promulgation of explicit clinical policy embodied in practice guidelines has recently heightened awareness of the determinants of medical decision making [2]. Practice guidelines have been developed to improve the process of health care and health outcomes, decrease practice variation, and optimize resource utilization [3, 4]. Described as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [5], guidelines attempt to distill a large body of medical expertise into a convenient, readily usable format. Practice guidelines based on the synthesis of the best, most recent evidence can help practitioners keep current with the literature and help them assimilate evidence into practice [6, 7]. The term guideline is used loosely to describe documents with different purposes, such as regulation of hospital admissions, use of tests and technology, transfer of seriously ill patients [8], and training programs [9]. Sporting such names as practice policies, practice parameters, and clinical indicators [10, 11], other decision aids further expand this lexicon. Clinical practice guidelines represent specific decision nodes that can be linked together to form clinical pathways or algorithms. Clinical pathways organize, sequence, and time the care given to a typical, uncomplicated patient [4, 12], whereas clinical algorithms are a set of more complex instructions for addressing a particular issue in which decisions and their consequences are expressed in conditional, branching logic [13]. This article focuses on the relation between systematic reviews and practice guidelines: how the development of guidelines can benefit from systematic reviews, and how systematic reviews can be used to help implement guidelines. Methods for Developing Guidelines: An Overview Methods used to develop guidelines differ according to the stakeholders involved, the degree of reliance on formal literature reviews, the extent to which expert opinion prevails, and the process by which the ultimate recommendations are expressed [11]. A multidisciplinary team may result in a holistic approach and wider endorsement of the final product [7]. Group processes commonly used to generate clinical recommendations include informal peer committees, nominal group techniques [14], the Delphi method [15], and expert or nonexpert consensus conferences. These strategies are not mutually exclusive, and their advantages and disadvantages have been summarized elsewhere [16]. One method for guideline development is outlined in the (Figure 1). Whether guidelines are created by local health providers, regional or national professional bodies, payers, or purchasers, the resources available may also determine the focus and methods. Few studies have compared the process, products, and health outcomes of these different approaches to developing recommendations [17]. Figure 1. One approach to developing guidelines and pathways on the basis of summaries of the relevant research evidence Selecting the clinical problem to be addressed by a guideline involves considering the prevalence of the problem, the clinical and economic burden it imposes, the resources available for its care, the availability of evidence for both existing care and improved care, and the likelihood of influencing practice [18, 19]. The next steps involve learning about current clinical practice as a baseline for change, defining the goals of the guidelines, and searching for the relevant research evidence (Figure 1). Because a guideline based on an incomplete or biased evaluation of the literature can lead to inappropriate recommendations, the search for relevant research should be comprehensive, research should be selected by using explicit criteria, and the validity of the results should be judged in a rigorous and reproducible fashion. Guideline and pathway developers ideally search for, select, critique, and combine data in a manner analogous to that used for a systematic review. In addition to incorporating evidence and acknowledging its absence, creating clinical recommendations requires making value judgments about preferred courses of action. Some guidelines lay out choices and are distinctively influenced by patient preferences. Consider the difference in this regard between offering men with prostate cancer the choice of conservative management or radical prostatectomy (which builds patient preference into the decision) and assuming that all patients without advance directives who sustain a cardiac arrest want cardiopulmonary resuscitation (which does not). Guideline documents ideally indicate how disagreements were handled and how information was synthesized (for example, by a qualitative pooling of opinion, a quantitative approach such as meta-analysis or decision analysis, or some combination of methods [19]). If guideline developers do not indicate how they identified and summarized the evidence and integrated different values, clinicians cannot adequately evaluate the rigor of the guidelines and the extent to which research evidence supports the recommendations [20, 21]. Recent guidelines for the diagnosis and treatment of idiopathic thrombocytopenic purpura [22] described the literature, emphasized the paucity of evidence and the limitations of opinion-based recommendations, and issued recommendations on the basis of clear documentation of the strength and variance of opinion [23]. The Role of Research Evidence in Practice Guideline Development Guideline developers who want to incorporate research evidence into their clinical recommendations recognize the challenges of exhaustively searching the literature. For many common conditions, the volume of clinically useful literature is considerable. For other conditions, data may be sparse. Because guideline development is often limited by the difficulty of locating and appraising primary research, searching for and conducting systematic reviews is important. Accordingly, both primary research and integrative articles are potentially useful to guideline developers (Figure 1). Systematic reviews are the most common type of integrative article. Their authors have searched for, selected, and synthesized (either qualitatively or quantitatively) evidence on specific clinical questions. Economic analyses quantitatively compare the costs and consequences of alternate courses of action. Decision analyses present the probability of various outcomes in terms of the values of expected benefits and harms of key decisions. Although clinical recommendations may emerge from these documents, their content is typically structured in a research report format. In contrast, practice guidelines are more often presented in a framework congruent with decision making; they suggest or support specific clinical recommendations but may reflect the scope of information contained in systematic reviews, economic analyses, and decision analyses. For example, the American College of Physicians guidelines for magnetic resonance imaging of the brain and spine [24] were produced after a systematic review of neuroimaging with magnetic resonance imaging [25], and the guideline developers acknowledged the absence of studies comparing magnetic resonance imaging with other technologies. Relevant reviews are sometimes published after rather than before guidelines are developed. Such was the case with the 1994 clinical practice guideline on unstable angina by the Agency for Health Care Policy and Research [26], whose expert panel recommended that patients with unstable angina who are receiving aspirin should be treated with heparin for 2 to 5 days unless heparin is contraindicated. Two years later, a supporting meta-analysis showed a 33% reduction in risk for myocardial infarction or death in patients who had unstable angina and received aspirin plus heparin compared with those who received aspirin alone [27]. The scope of guidelines may reflect the particular interests of the guideline developers. The Colleges guidelines for the medical treatment of stroke prevention [28] clearly incorporate the results of a concurrently published systematic review [29] but are not explicit about cost-effectiveness issues (such as the rationale for choosing aspirin rather than ticlopidine). Other guidelines, such as those created by the American Heart Association for carotid endarterectomy [30], comprehensively summarize research and address economic issues more directly. Examples of How To Use Systematic Reviews for Building Practice Guidelines and Clinical Pathways As an alternate or complementary approach to formally summarizing primary research, guideline and pathway developers can use previously published systematic reviews that summarize the relevant primary studies. For the management of bleeding esophageal varices, approximately 200 randomized trials of pharmacologic, mechanical, and surgical interventions could be considered, as could a more manageable number of systematic reviews of these topics. For example, systematic reviews of primary prevention of variceal gastrointestinal hemorrhage indicate that -blockade and sclerotherapy reduce bleeding and mortality rates [31-33]. Systematic reviews also indicate the following. First, for control of acute bleeding, vasopressin is superior to no treatment but somatostatin is more effective than vasopressin [34, 35]. Second, although emergency sclerotherapy controls bleeding and

Meta-Analysis: Angiotensin-Receptor Blockers in Chronic Heart Failure and High-Risk Acute Myocardial Infarction

Angiotensin-receptor blockers (ARBs) were first introduced into the marketplace in the early 1990s and have been used to treat various conditions, including hypertension and heart failure (1). Angiotensin-receptor blockers reduce afterload and increase cardiac output in heart failure (2, 3), similar to the mechanism of action seen with angiotensin-converting enzyme (ACE) inhibitors, while also reversing left ventricular remodeling (4). The benefits of ACE inhibitors might also be partly attributed to prevention of the formation of inflammatory cytokines by angiotensin II (5-7). A study has suggested that ARBs could share similar anti-inflammatory properties (6). The American College of Cardiology/American Heart Association (ACC/AHA) (8) and the Heart Failure Society of America (HFSA) (9) recommend that ACE inhibitors be preferred over ARBs for patients with heart failure and left ventricular systolic dysfunction but state that ARBs may be considered for patients who are intolerant of ACE inhibitors. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (10) and the Centers for Medicare & Medicaid Services (CMS) (11) have defined quality indicators for patients with heart failure and acute myocardial infarction (MI), which currently include administering ACE inhibitors as first-line therapy for patients with an ejection fraction less than 0.40. Neither JCAHO nor the CMS has defined quality indicators for ARB administration, and they have not recognized ARB therapy as an acceptable reason for not administering ACE inhibitors. This may have occurred partly because of the inconclusive and conflicting nature of the data in previously published randomized, controlled trials about the effect of ARBs on death and hospitalizations. A 2000 systematic review by Flather and colleagues (12) showed that ACE inhibitors result in lower mortality and heart failure hospitalizations as compared with placebo in patients with heart failure and left ventricular systolic dysfunction. However, a 2002 meta-analysis by Jong and colleagues (13) included randomized, controlled trials published up to May 2001 and showed no statistically significant difference in mortality or heart failure hospitalization rates between ARBs and placebo in patients with heart failure and left ventricular systolic dysfunction. Since May 2001, the largest series of randomized, controlled trials evaluating ARBs in chronic heart failure, Candesartan in Heart FailureAssessment of Reduction in Mortality and Morbidity (CHARM) (14-17), has been published. In the CHARM-Alternative trial (15), patients who were intolerant of ACE inhibitors were randomly assigned to candesartan or placebo. The results showed that candesartan was associated with a statistically significant reduction in heart failure hospitalization but only a nonstatistically significant reduction in all-cause mortality. Data from randomized, controlled trials evaluating ARBs and ACE inhibitors in patients with high-risk acute MI (defined as acute MI complicated by heart failure) have also been recently published in the Optimal Trial in Myocardial Infarction with the Angiotensin II Antagonist Losartan (OPTIMAAL) (18) and Valsartan in Acute Myocardial Infarction (VALIANT) trial (19). Researchers have recommended that meta-analyses be continually updated as new and relevant randomized, controlled trials are published since meta-analyses may quickly become outdated (20, 21). The objective of this meta-analysis is to incorporate data from recently published randomized, controlled trials into the pool of evidence and to determine whether recently published research affects the statistical significance of efficacy outcomes for the use of ARBs in chronic heart failure and high-risk acute MI. Methods Data Sources We reviewed the medical literature to identify studies evaluating the efficacy of ARBs in patients with chronic heart failure and high-risk acute MI. We searched for articles from the following medical bibliographic databases: Cochrane Central Register of Controlled Trials (third quarter 2003), Cochrane Database of Systematic Reviews (third quarter 2003), Cumulative Index to Nursing and Allied Health Literature (1982 to November week 1 2003), Database of Abstracts of Reviews of Effects (third quarter 2003), HealthSTAR (1975 to October 2003), and MEDLINE (1966 to present). The search included terms related to heart failure and acute MI (cardiac failure, cardiac insufficiency, congestive heart failure, coronary disease, heart failure, and myocardial infarction) that were combined with terms related to ARBs (angiotensin receptors, candesartan, elisartan, embusartan, eprosartan, forasartan, irbesartan, losartan, olmesartan, saprisartan, tasosartan, telmisartan, valsartan, and zolasartan) using Boolean operators and syntax that were appropriate for each database. We also manually searched references from selected clinical trials and review articles. Finally, we reviewed abstracts from the 2002 and 2003 conference proceedings of the ACC, AHA, Canadian Cardiovascular Society (CCS), European Society of Cardiology (ESC), and HFSA. Study Selection We followed a written protocol with explicit article selection criteria. We rejected articles at the title and abstract stage if they were not randomized, controlled trials; were not written in English; did not address patients with chronic heart failure or high-risk acute MI; did not compare ARBs versus an appropriate control group (ARBs vs. placebo, ARBs vs. ACE inhibitors, or ARB plus ACE inhibitor combinations vs. ACE inhibitors alone); or did not enroll human participants. We subjected the full text of remaining articles to the same criteria and rejected them if all-cause mortality and heart failure hospitalization outcomes were not reported or the follow-up duration was less than 4 weeks. Data Extraction Two reviewers used a standardized form to independently extract information on study design, sample characteristics, sample size, intervention strategies, outcome measures, and other study characteristics from included randomized, controlled trials. We assessed the methodologic quality of randomized, controlled trials by using a scoring system developed by Jadad and colleagues (22). We obtained raw data, when available, for all-cause mortality and heart failure hospitalization outcomes from intention-to-treat analyses. Heart failure hospitalization was defined as the number of patients with 1 or more postrandomization admissions for heart failure, for complications from treatment of heart failure, or for management of comorbid conditions associated with heart failure. For studies in which patients were randomly assigned to 1 of several dosage groups of the same study medication, we pooled outcomes from those groups for the analysis. We resolved discrepancies through discussion and consensus opinion or by contacting the corresponding author of the original clinical trial. Statistical Analysis We calculated values for agreement by using the methods described by Fleiss (23). We calculated an odds ratio for each study outcome to allow for pooling of similar outcomes. For studies in which 1 of the randomization groups had no events, we used a continuity correction factor (that is, adding 0.5 to each cell) to avoid dividing by 0 (23). We reported results as the pooled odds ratio with 95% CIs. We calculated pooled odds ratios and 95% CIs for random-effects models on the basis of the methods of DerSimonian and Laird (24), and we used the MantelHaenszel (25) method for fixed-effects models. We used a chi-square test to assess heterogeneity. We sorted data into 3 main comparison groups: ARBs versus placebo, ARBs versus ACE inhibitors, and ARB and ACE inhibitor combinations versus ACE inhibitors alone (including comparisons of ARBs vs. placebo for studies in which patients received ACE inhibitors in both groups). We performed sensitivity analyses for each group to determine how the prespecification of end points influenced results. In the presence of statistical heterogeneity, defined as a chi-square test P value less than 0.10, we analyzed the data by using random-effects models. Otherwise, we used fixed-effects models. The P value threshold for statistical significance was set at 0.05 for effect sizes. We performed statistical calculations by using Stata, version 8.1 (Stata Corp., College Station, Texas), and RevMan, version 4.2.6 (The Cochrane Collaboration, Oxford, United Kingdom). We generated a funnel plot (by using Excel 2000 [Microsoft Corp., Redmond, Washington]) of randomized, controlled trials with estimable odds ratios for all-cause mortality in chronic heart failure to assess the presence of publication bias. We plotted the inverse of the standard error of the natural logarithm of the odds ratio against the natural logarithm of the odds ratio. Role of the Funding Source The funding source had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication. Data Synthesis Included Studies Figure 1 presents an article flow diagram. From the initial search of all medical bibliographic databases, we identified 1603 articles. After we excluded duplicates, 1158 unique records remained. On the basis of prespecified exclusion criteria, we rejected 1074 articles during title and abstract review. The value from the title and abstract review was 0.76. We rejected another 62 articles during the full-text review, yielding a total of 22 articles. We excluded 1 study (26) from the pooled analysis because we could not reconcile the distribution of patient deaths across study groups despite communication with the corresponding author. A manual search of relevant articles revealed 2 additional phase III randomized, controlled trials (27) whose raw data were presented in a meta-analysis, as well as the VALIANT study (19), which was published on the day of our search. Our search of abstracts f

A statewide initiative to improve the care of hospitalized pneumonia patients: The Connecticut Pneumonia Pathway Project.

PURPOSE A statewide quality improvement initiative was conducted in Connecticut to improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia. SETTING AND METHODS Data were collected on 1,242 elderly (> or =65 years) pneumonia patients hospitalized at 31 of 32 acute care hospitals between January 16, 1995, and March 15, 1996, and on 1,146 patients hospitalized between January 1, 1997, and June 30, 1997. Interventions included feedback of performance data (Qualidigm, the Connecticut Peer Review Organization), dissemination of an evidence-based pneumonia critical pathway (Connecticut Thoracic Society), and sharing of pathway implementation experiences (hospitals). Process and outcome measures included early antibiotic administration, blood culture collection, oxygenation assessment, length of stay, 30-day mortality, and 30-day readmission rates. Analyses were adjusted for severity of illness and hospital-specific practice patterns. RESULTS After the statewide initiative, improvements were noted in antibiotic administration within 8 hours of hospital arrival (improvement from 83.4% to 88.8%, relative risk [RR] = 1.21; 95% confidence interval [CI]: 1.10 to 1.32), oxygenation assessment within 24 hours of hospital arrival (93.6% to 95.4%; RR = 1.23, 95% CI: 1.11 to 1.38), and length of stay (7 days to 5 days, P <0.001). There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30-day mortality, or 30-day readmission rates. CONCLUSIONS Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention. Further research is needed to separate the effects of the quality improvement interventions from secular trends.

Do hospital employees benefit from the influenza vaccine?: A placebo-controlled clinical trial

Although current guidelines target hospital employees who contact high-risk patients as a high priority for influenza immunization, there are few data to support or refute this recommendation. Therefore, the authors enrolled 179 hospital employees in a randomized double-blind placebo-controlled clinical trial during the 1985–1986 influenza season. Influenza immunization was performed without serious adverse reactions and there was no increase in absenteeism attributable to the vaccination. Among those who developed clinical influenza, there was a trend toward fewer days of illness in the vaccinated group compared with the placebo group (6.0 vs. 8.0, p=0.07). There were no statistically significant differences between subjects receiving influenza vaccine and those receiving the placebo when comparing incidences of influenza-like illness, severities of illness, and sick absenteeism. Influenza immunization of hospital employees was performed at minimal cost and risk but provided little benefit, most likely because of an unexpected drift of the prevalent influenza strain away from the vaccine type.

Early Step-Down Transfer of Low-Risk Patients with Chest Pain: A Controlled Interventional Trial

OBJECTIVE To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN Prospective, controlled, interventional trial using an alternate month study design. SETTING A large teaching community hospital. PATIENTS Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by

Physician education and report cards: do they make the grade? Results from a randomized controlled trial

2.6 million per year and profits improved by

Using practice guideline compendiums to provide better preventive care.

390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Can Practice Guidelines Be Transported Effectively to Different Settings? Results from a Multicenter Interventional Study

PURPOSE We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction. SUBJECT AND METHODS We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed. RESULTS Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P <0.01, and 80% versus 91%, P <0.01), pneumococcal immunization (42% versus 73%, P < 0.01 and 34% versus 73%, P < 0.01), and tetanus immunization (64% versus 72%, P <0.01, and 59% versus 79%, P <0.01). Mammography (90% versus 80%, P <0.01) and clinical breast examination (85% versus 79%, P <0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20). CONCLUSION A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care.

Physicians’ Changing Attitudes Toward Guidelines

During the past decade, an increasing number of preventive care and other guidelines have been published in articles and textbooks and on the Internet (1-4). However, with the proliferation of this new and potentially important information, practitioners may become increasingly bewildered in their attempts to sort through the vast number of guidelines and decide which are most appropriate for their patients. The accelerated pace of development has led to an abundance of guidelines created by different organizations with different methods and different objectives (1-4). The quality and rigor of the guidelines vary widely. To address the propagation of preventive care and other guidelines, compendiums have been assembled to organize and integrate existing guideline information into a single source. I describe 1) the rationale for continued attention to preventive care guidelines, 2) recent efforts to organize existing guidelines, 3) currently available compendiums of preventive care guidelines, 4) how the compendiums may be used in day-to-day practice, and 5) how this information may be used to improve the provision of preventive care. Rationale for Continued Focus on Preventive Care Guidelines Despite the plethora of preventive care guidelines, significant gaps remain between appropriate levels of preventive care and levels of preventive care documented in clinical practice (5, 6). Moreover, missed opportunities to provide preventive care can cause substantial human consequences (5, 6). Because researchers believe that 70% of disease is preventable (6, 7), effective implementation of preventive care guidelines can lead to even greater improvements in patient care than the introduction of some new technologies. For example, if a health plan that provides service to 100 000 women between the ages of 50 and 69 years increased mammography rates by approximately 10%, at least 14 lives over 10 years could be saved (8). Additional benefits, including reductions in mortality, morbidity, and suffering, could accrue from increasing the rates of provision of other recommended preventive care procedures (1, 7). Many preventive care recommendations have been published in the past, but wide gaps persist between published recommendations and actual practice. Until these gaps are closed, health care professionals will continue to consider how preventive care guidelines can be more effectively translated into clinical practice. Recent Efforts To Organize and Integrate Guidelines Guideline development can create new knowledge by systematically evaluating and integrating primary research studies with expert interpretation to develop specific recommendations (9, 10). Because many clinicians cannot stay current with all published literature on preventive care, guidelines may integrate and codify existing information into a more digestible format. Many health care organizations have developed practice guidelines, including preventive care guidelines, leading to a virtual explosion in the amount of guidelines available. As a result, the challenge of having the most recent information about preventive care guidelines has become daunting; efforts are under way to organize and integrate existing guidelines and make them more accessible, usable, and comprehensible. Although practice guidelines organize and integrate available primary research and opinion into codified recommendations, practice guideline compendiums may organize and integrate different sources of practice guidelines. Available Compendiums of Preventive Care Practice Guidelines Available sources of compiled and organized guidelines include 1) Clinicians Handbook of Preventive Services [1], 2) National Guideline Clearinghouse [4], 3) Clinical Practice Guidelines Directory [11], and 4) U.S. Preventive Services Task Force Guide to Clinical Preventive Services (3). The Clinicians Handbook of Preventive Services (www.intlmedpub.com) focuses exclusively on preventive care, provides additional information to assist clinicians in the provision of preventive care services (for example, information about provider and patient resources and practical pointers), and includes information on available preventive care guidelines. However, the Clinicians Handbook includes limited screening criteria to distinguish guidelines that are less rigorous from those that are evidence based and offers scant information to familiarize readers with the reasons different guidelines may conflict. The National Guideline Clearinghouse (www.guideline.gov) attempts to explain conflicts and sets a minimal standard for inclusion in the compendium. The National Guideline Clearinghouse, however, does not specifically focus on preventive care. The Clinical Practice Guidelines Directory (www.ama-assn.org) serves as a repository of guidelines on more than 2000 topics from more than 90 organizations. It is easy to use and can quickly point a reader toward the sources of guidelines on relevant topics. The U.S. Preventive Services Task Force Guide to Clinical Preventive Services (lww.com) is an evidence-based source of preventive care recommendations; this guide summarizes the available scientific evidence and opinions of experts in preventive care and primarily focuses on U.S. Preventive Services Task Force guidelines rather than guidelines from other sources. Clinicians Handbook of Preventive Services The Clinicians Handbook of Preventive Services has recently published a second edition of preventive care guidelines to serve as a comprehensive resource for practitioners and students interested in preventive medicine. The book has been published by the Agency for Health Care Policy and Research and serves as a repository of primary preventive care recommendations from federal and private organizations, such as federal health sources (for example, the Centers for Disease Control and Prevention), nonfederal authoritative bodies (for example, the U.S. Preventive Services Task Force), and national health organizations (for example, the American Cancer Society). This book is useful because it sifts through the many preventive care guidelines available from journals, books, the Internet, and other sources and compiles them in one resource. The Clinicians Handbook of Preventive Services includes information about immunization, screening tests to assist in the early diagnosis of disease, techniques to prevent disease, and behavioral modification and counseling. The targeted conditions are associated with a substantial burden of disease in the population. The book can also serve as a reference guide for clinicians and administrators or be used as a source book to create protocols and guidelines. Background information on the condition and disease, summaries of recommendations published by recognized authorities in preventive care and medicine, information on how each preventive care procedure is performed, and a directory of resources for providers and patients (for example, pamphlets and videotapes for providers and patients) are provided. All of the information is annotated, which allows the user to find supporting information if necessary. National Guideline Clearinghouse Another resource available on the Internet is the National Guideline Clearinghouse, which includes guidelines that meet specific criteria for being evidence-based. The Agency for Health Care Policy and Research, in partnership with the American Association of Health Plans and the American Medical Association, has invited developers of practice guidelines, including professional societies, to submit guidelines for possible inclusion in the National Guideline Clearinghouse. Guidelines must contain systematically developed statements that satisfy the Institute of Medicines definition of a guideline (9, 10); be developed under the auspices of a medical organization; be derived from a systematic review of the relevant literature and science; have been developed, reviewed, or revised in the past 5 years; and be available in English. The National Guideline Clearinghouse systematically organizes and displays guidelines, including a structured abstract on the guideline and how it was developed, a comparison of guidelines highlighting areas of agreement and conflict, and the full guideline text (or links to the text). In addition, a forum allows guideline users to exchange information on the development, implementation, and evaluation of guidelines. The subject matter of some of these guidelines relates to preventive care. How To Use the Practice Guideline Compendiums Compendiums to practice guidelines will be useful if they can quickly answer important clinical questions. The answers may relate to the care of an individual patient (should I order mammography for this 47-year-old woman without a family history of breast cancer?) or the care of a population of patients. The following hypothetical situation addresses the use of a preventive care guideline compendium to research a question that is relevant to the care of a population of patients. You are a primary care physician and belong to an independent practice association (IPA). Last month, you received a HEDIS (Health Plan Employer Data Information Set) report card from the IPA that listed your mammography rate as 63%, 5% below the average for primary care physicians in the IPA. You are aware that the medical director of the independent practice organization will be basing your compensation, in part, on compliance with HEDIS guidelines, including guidelines for mammography. After reading the letter, you are unsure how the IPA measured your mammography rate and you question the validity of the results. Furthermore, you are aware of recent controversies about mammography, including when mammography should be initiated, the age at which mammography is no longer necessary (if ever), and the appropriate interval for performing mammography (every 1 or 2 years). You search the Clinicians Handbook of Preventi