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Of Guides and Guidelines

tions, and applying these in a timely fashion for today's patient has become increasingly difficult for even the most skilled and focused practitioner. The difficulties in the uniform application of these skills is evident in the marked variation in practice(s) reported in investigations of interventions in different populations in the United States.1 Attempts to understand these variations and to come to consensus in order to optimize the use of medical care resources has led a broadening group of medical professionals to explore the development and use of various guidelines.2 It is then a small step from the issuance of such guidelines to their use by various agencies as standards or indicators by which "quality of care" may be explored. The development of guidelines and their derivative indicators in a practice target area is both deceptively simple and immediately contentious. The topic literature is rarely uniform in either quality of study or details of intervention and almost never in the described characteristics of the population(s) included. The information required for guideline development and their application includes standard nomenclatures and definitions, common classifications, linkages over time, determination of stage, severity, and comorbidities in the host patient, and standard judgments of outcome, including those related to comfort and function. Except for major cooperative studies, similar groupings of sufficient size for comparative analysis are frequently unavailable. Application of a guideline for evaluation requires, at a minimum, acceptable comparable data in retrievable form, archival data bases for storage, editing, and analysis, and the standard communication links necessary to tie this process together. Group analysis and comparisons over time may then provide the screening feedback critical to recognizing variations that can be studied and linked at the local or personal level to changes (improvements) in the care process for better patient outcomes. Experience indicates that we, as individuals or as institutions, are rarely comfortable as poorly performing outliers and that most often we