Purpose The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety. Principal findings The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue. Conclusions Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.
RésuméObjectif L'objectif de cette analyse est de discuter de l'impact des directives de pratique clinique sur les re´sultats des soins et sur la se´curite´des patients. Constatations principales Le niveau des soins fournis aux patients peut varier dans de grandes proportions, et cela concerne e´galement certains soins qui ne concordent pas avec les donne´es probantes disponibles. Ce manque d'homoge´ne´ite´a des implications sur la se´curite´des patients, car certains d'entre eux reçoivent des soins qui ont peu de chances de leur eˆtre be´ne´fiques ou qui leur sont plutôt ne´fastes, tandis que d'autres se voient refuser des soins qui pourraient manifestement leur eˆtre utiles. Les publications me´dicales se multiplient a`un rythme inquie´tant; leur qualite´et leur fiabilite´sont souvent faibles; la me´thodologie des e´tudes est souvent sous-optimale et leurs conclusions sont souvent contredites, meˆme dans le cas d'articles fre´quemment re´fe´rence´s. Pendant des de´cennies, les socie´te´s savantes de spe´cialistes et les agences gouvernementales ont fourni des directives de pratique clinique pour aider les me´decins a`inte´grer les donne´es probantes dans les processus de prise de de´cision clinique. La mise en oeuvre des directives a e´te´variable et, souvent, leurs objectifs ne sont pas atteints en raison de leur non-adoption par les profe...