Towards evidence-based clinical practice:: an international survey of 18 clinical guideline programs

Objective. To describe systematically the structures and working methods of guideline programs. Design. Descriptive survey using a questionnaire with 32 items based on a framework derived from the literature. Answers were tabulated and checked by participants. Study participants. Key informants of 18 prominent guideline organizations in the United States, Canada, Australia, New Zealand, and nine European countries. Main outcome measures. History, aims, methodology, products and deliveries, implementation, evaluation, procedure for updating guidelines, and future plans. Results. Most guideline programs were established to improve the quality and effectiveness of health care. Most use electronic databases to collect evidence and systematic reviews to analyze the evidence. Consensus procedures are used when evidence is lacking. All guidelines are reviewed before publication. Authorization is commonly used to endorse guidelines. All guidelines are furnished with tools for application and the Internet is widely used for dissemination. Implementation strategies vary among different organizations, with larger organizations leaving this to local organizations. Almost all have a quality assurance system for their programs. Half of the programs do not have formal update procedures. Conclusions. Principles of evidence-based medicine dominate current guideline programs. Recent programs are benefiting from the methodology created by long-standing programs. Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors. International collaboration should be encouraged to improve guideline methodology and to globalize the collection and analysis of evidence needed for guideline development.