Clinical guidelines-the hidden costs

Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline

Aims: Chronic obstructive pulmonary disease (COPD) is a common condition associated with considerable morbidity, mortality and hospital admissions. However, published COPD management guidelines have major limitations and lack practical summaries. We aimed to optimally develop, implement, and evaluate a multidisciplinary COPD inpatient management ‘ACCORD’ guideline, including prompts for comprehensive day one assessments through to a discharge criteria checklist. Method: Two intervention and two control public teaching hospitals in Adelaide, South Australia, took part, with pre-intervention (721 COPD admissions over 7 months) and intervention phases (509 COPD admissions over 7 months). During the intervention stage the ACCORD guideline was placed in the case notes on the day of admission or soon after. Readmissions were categorized as either emergency or elective and compared between the study arms, as were mortality and potential confoundeis (age, gender, number of comorbidities), with Poisson regression analysis. Results: Of case notes of eligible COPD patients, 60% had the ACCORD guideline placed, of which 76% had evidence of use as judged by completion of guideline entry and tick boxes. The ACCORD guideline was associated with an increase in elective admissions and a reduction in emergency admissions in the intervention group in relation to the control group (P < 0.01), with no difference in overall admissions or death rates. Conclusions: The ACCORD guideline was associated with a shift from emergency admissions to more planned elective care, suggesting more proactive care of health problems, but without overall reduction in admissions.

Clinical guidelines in community hospitals

Nineteen F and G grade nurses, one practice development nurse, two physiotherapists and two occupational therapists working in 11 community hospitals in Leicestershire and Rutland were interviewed about their use of clinical guidelines and their attitude towards them. They were asked questions about sources of clinical guidelines, and a simple gap analysis was carried out.

The interviewees were able to identify clinical guidelines that were used locally, and human and organisational resources of guidelines: resource rooms, practice development nurses, link nurses and study days.

The use of link nurses, and regular study days, both of which provide cascade learning, work well. Furthermore, in the opinion of the ward nurses, the practice development nurse has a useful role in making nurses aware of guidelines.

Generally, the responses about the use of clinical guidelines were positive, although some reservations were noted. There was agreement that regular professional meetings and ward hand-overs provide a natural and effective dissemination route.

The interviewees were not aware of any national clinical guidelines. Despite many of the interviewees having access to the internet (generally from home rather than from the hospitals), none could identify any online resources for clinical guidelines or knew that they existed.

Developing clinical guidelines for end-of-life care: blending evidence and consensus

BACKGROUND

Developing clinical practice guidelines (CPGs) is challenging, particularly in areas that are difficult to research such as end-of-life care.

AIM

To describe the process that staff in a large regional health-care service in Victoria, Australia, used to develop CPGs for managing diabetes at the end of life.

METHOD

An interdisciplinary advisory group was appointed, a structured literature review undertaken, personal illness accounts sourced, and a guiding philosophy formulated. Individual interviews were conducted with people with diabetes and their carers. Formative and summative evaluation was undertaken.

RESULTS

No level I or II evidence was identified. The interviews yielded important information about how people wanted their diabetes managed. Formative evaluation enabled stakeholders to participate in developing the CPGs. The summative evaluation confirmed the CPGs are easy to use and appropriate to clinical staff.

CONCLUSIONS

The CPG development process yielded the best current evidence on which to base care plans and person-centred CPGs.

Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation

AIM

This paper is a report of an investigation of the development, implementation and outcomes of a clinical guideline for nurse-led early extubation of adult coronary artery bypass graft patients.

BACKGROUND

Healthcare knowledge translation and utilization is an emerging but under-developed research area. The complex context for guideline development and use is methodologically challenging for robust and rigorous evaluation. This study contributes one such evaluation.

METHODS

This was a mixed methods evaluation, with a dominant quantitative study with a secondary qualitative study in a single UK cardiac surgery centre. An interrupted time series study (N = 567 elective coronary artery bypass graft patients) with concurrent within person controls was used to measure the impact of the guideline on the primary outcome: time to extubation. Semi-structured interviews with 11 clinical staff, informed by applied practitioner ethnography, explored the process of guideline development and implementation. The data were collected between January 2001 and January 2003.

RESULTS

There was no change in the interrupted time series study primary outcome as a consequence of the guideline implementation. The qualitative study identified three themes: context, process and tensions highlighting that the guideline did not require clinicians to change their practice, although it may have helped maintain practice through its educative role.

CONCLUSION

Further investigation and development of appropriate methods to capture the dynamism in healthcare contexts and its impact on guideline implementation seems warranted. Multi-site mixed methods investigations and programmes of research exploring knowledge translation and utilization initiatives, such as guideline implementation, are needed.

Medication adherence issues in patients treated for COPD

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

Do clinical guidelines enhance safe practice in obstetrics and gynaecology?

Clinical guidelines are increasingly used to promote a more uniform standard of high-quality evidence-based health care. International agencies advocate guideline development methods founded on three principles: that recommendations are evidence-based, are explicitly linked to the type and quality of evidence, and are developed by multidisciplinary stakeholder groups. Numerous interventions have been described to support the implementation of guidelines. Systematic reviews suggest that most interventions produce modest to moderate improvements in care; multifaceted interventions appear to be no more effective than single interventions, and the lowest-cost implementation strategy (dissemination of printed materials) may improve care and be feasible in many settings. Given the considerable costs of developing valid guidelines de novo, we advocate local adaptation of existing guidelines if available. We suggest a pragmatic framework to assist policy-makers and clinicians in deciding how best to use the scarce resources available for quality-improvement activities.

Eminence-based guidelines: a quality assessment of the second Joint British Societies' guidelines on the prevention of cardiovascular disease

The quality and independence of clinical practice guidelines developed by professional societies has previously been assessed as unsatisfactory. Calls for explicit methodological standards have lead to international consensus on standards for guideline development. The methodological quality of current British cardiovascular guidelines produced by six professional societies is assessed with reference to internationally recognised criteria (Appraisal of Guidelines Research and Evaluation) for evaluating the quality of clinical guidelines. When evaluated with reference to a recognised quality framework for guideline development, current Joint British Societies guidelines for the prevention and treatment of cardiovascular disease contain serious deficiencies, are of low quality and should not be recommended for clinical practice.

Risk-based evaluation of thromboprophylaxis among surgical inpatients: are low risk patients treated unnecessarily?

BACKGROUND

Venous thromboembolism is a common source of morbidity and mortality but a variety of preventative measures are available.

AIMS

To audit the current practice of thromboprophylaxis and compare against published protocols.

METHODS

Three-hundred and seventy-six (376) surgical patients were surveyed prospectively. A Performa was completed recording the presence of up to 11 risk factors. A risk score was calculated and the use of specific thromboprophylatic measures identified.

RESULTS

Heparin thromboprophylaxis was widely used, eight patients (who were on aspirin therapy) failed to receive any prophylaxis (risk factors 4-6). In addition there were 60 patients at low risk (risk score <2) received LMWH from which they were unlikely to benefit.

CONCLUSIONS

Thromboembolic prophylaxis is widely but unselectively applied. Adoption of a risk: benefit ratio approach should ensure those who would benefit from thromboprophylaxis are adequately treated while those in whom thromboprophylaxis is not indicated are spared unnecessary therapy.

Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects

OBJECTIVES

The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs.

METHODS

An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors.

RESULTS

The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management.

CONCLUSIONS

Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.

Aspekte zur gesundheitsökonomischen Bewertung im Gesundheitssystem

Health economists use models to estimate comparative costs and usage of interventions in health care. However the concepts and methods used have inherent weaknesses, especially in the determination of relevant and exact effect sizes. Health economic methodologies do not replace sociopolitical decision making, but they can play an important role in rational decision making about necessary changes to our social and health system if the instruments themselves are neither over- nor underestimated.

Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease

OBJECTIVES

To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD).

METHODS

1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients.

RESULTS

1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission.

CONCLUSIONS

1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.

Treatment of Lyme disease: a medicolegal assessment

Lyme disease is the most common tick-borne disease in the world today. Despite extensive research into the complex nature of Borrelia burgdorferi, the spirochetal agent of Lyme disease, controversy continues over the diagnosis and treatment of this protean illness. This report will focus on two aspects of the treatment of Lyme disease. First, the medical basis for diagnostic and therapeutic uncertainty in Lyme disease, including variability in clinical presentation, shortcomings in laboratory testing procedures, and design defects in therapeutic trials. Second, the standard of care and legal issues that have resulted from the clinical uncertainty of Lyme disease diagnosis and treatment. Specifically, the divergent therapeutic standards for Lyme disease are addressed, and the difficult process of creating treatment guidelines for this complex infection is explored. Consideration by healthcare providers of the medicolegal issues outlined in this review will support a more rational approach to the diagnosis and treatment of Lyme disease and related tick-borne illnesses.

A review of clinical guidelines

Background

Clinical guidelines are increasingly used in patient management but few clinicians are familiar with their origin or appropriate application.

Methods

A Medline search using the terms ‘clinical guidelines’ and ‘practice guidelines’ was conducted. Additional references were sourced by manual searching from the bibliographies of articles located.

Results and conclusion

Clinical guidelines originated in the USA in the early 1980s, initially as a cost containment exercise. Significant improvements in the process and outcomes of care have been demonstrated following their introduction, although the extent of improvement varies considerably. The principles for the development of guidelines are well established but many published guidelines fall short of these basic quality criteria. Guidelines are only one aspect of improving quality and should be used within a wider framework of promoting clinical effectiveness. Understanding their limitations as well as their potential benefits should enable clinicians to have a clearer view of their place in everyday practice.

Developing primary care review criteria from evidence-based guidelines: coronary heart disease as a model

BACKGROUND

National Health Service (NHS) initiatives such as Clinical Governance, National Service Frameworks and the National Institute of Clinical Excellence (NICE) clinical guidelines programme create demand for tools to enable performance review by healthcare professionals. Ideally such tools should enable clinical teams to assess quality of care and highlight areas of good practice or where improvement is needed. They should also be able to be used to demonstrate progress towards goals and promote quality, while not unnecessarily increasing demand on limited resources or weakening professional control.

AIM

To formulate and evaluate a method for developing, from clinical guidelines, evidence-based review criteria that are proritised, useful and relevant to general practices assessing quality of care for the primary care management of coronary heart disease (CHD).

DESIGN OF STUDY

A two-stage study comprising, first, a review of available evidence-based guidelines for CHD and, second, the definition and prioritization of associated review criteria from the most highly rated guidelines.

SETTING

Primary healthcare teams in England.

METHODS

Using structured methods, evidence-based clinical guidelines for CHD were identified and appraised to ensure their suitability as the basis for developing review criteria. Recommendations common to a number of guidelines were priortszid by a panel of general practitioners to develop review criteria suitable for use in primary care.

RESULTS

A standardised method has been developed for constructing evidence-based review criteria from clinical guidelines. A limited, prioritized set of review criteria was developed for the primary care management of CHD. This was distributed around the NHS through the Royal College of General Practitioners for use by primary care teams across the United Kingdom.

CONCLUSION

Developing useful, evidence-based review criteria is not a straightforward process, partly because of a lack of consistency and clarity in guidelines currently available. A method was developed which accommodated these limitations and which can be applied to the development and evaluation of review criteria from guidelines for other conditions.

ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand

This study explores Thai physicians' rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians' case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented.

Thromboprophylaxis can be omitted in selected patients undergoing varicose vein surgery and hernia repair

BACKGROUND

There is no current agreement on the routine use of thromboprophylaxis in patients undergoing varicose vein surgery and hernia repair. In the authors' hospital, prophylaxis is given only to those considered to be at an increased risk. A retrospective review was conducted to determine whether it was safe to omit prophylaxis in low-risk patients.

METHODS

Data were extracted from the hospital database about all patients who underwent the above procedures between January 1997 and December 2001. The case notes of patients who developed venous thromboembolism (VTE) within 3 months of surgery were reviewed. The pharmacy database was then analysed to determine the effect of prophylaxis.

RESULTS

A total of 4670 patients were identified. Some 2186 patients had varicose vein surgery; 1283 patients received prophylaxis, of whom four developed VTE. None of the 903 patients who did not receive prophylaxis developed VTE. A total of 2484 patients had hernia repair, of whom 1854 patients received prophylaxis and 630 did not; one patient from each group developed VTE.

CONCLUSION

Low-risk patients having hernia and vein surgery do not need thromboprophylaxis.

Clinical decision guidelines for NHS cosmetic surgery: analysis of current limitations and recommendations for future development

Because of increasing demand for publicly funded elective cosmetic surgery, clinical decision guidelines have been developed to select those patients who should receive it. The aims of this study were to identify: the main characteristics of such guidelines; whether and how they influence clinical decision making; and ways in which they should be improved. UK health authorities were asked for their current guidelines for elective cosmetic surgery and, in a single plastic surgery unit, we examined the impact of its guidelines by observing consultations and interviewing surgeons and managers. Of 115 authorities approached, 32 reported using guidelines and provided sufficient information for analysis. Guidelines mostly concerned arbitrary sets of cosmetic procedures and lacked reference to an evidence base. They allowed surgery for specified anatomical, functional or symptomatic reasons, but these indications varied between guidelines. Most guidelines also permitted surgery 'exceptionally' for psychological reasons. The guidelines that were studied in detail did not appreciably influence surgeons' decisions, which reflected criteria that were not cited in the guidelines, including cost of the procedure and whether patients sought restoration or improvement of their appearance. Decision guidelines in this area have several limitations. Future guidelines should: include all cosmetic procedures; be informed by a broad range of evidence; and, arguably, include several nonclinical criteria that currently inform surgeons' decision-making.

Are guidelines ethical? Some considerations for general practice

Guidelines have been promoted in various roles in general practice, e.g. to improve quality of care, to assist patient decision making, and to improve resource allocation. This paper examines these claims using ethical analysis. Guidelines may help general practitioners to act for thegood of their patients and avoid harm; but, on their own, guidelines cannot ensure quality of care or the protection of patients' interests. Patient choice may be limited rather than enhanced by following guideline recommendations. Guidelines contribute to rationing of resources but do not use explicit citeria for this. The ethical implications for guideline use are complex and far-reaching

Costs for screening, intervention and hospital treatment generated by the Malmö Preventive Project: a large-scale community screening programme

OBJECTIVES

The purpose of this study was to estimate retrospectively the costs of health care resources used in the Malmö Preventive Project, Sweden and estimate the costs of in-patient care that were avoided because of early intervention.

SETTING AND SUBJECTS

A large-scale community intervention programme was conducted from 1974 to 1992 in Malmö, Sweden with the aim of reducing morbidity and mortality of cardiovascular diseases (CVD), alcohol related illnesses, and breast cancer. Between 1974 and 1992, 33 336 male and female subjects were screened for hypertension, hyperlipidaemia, type-2 diabetes and alcohol abuse. Intervention programmes that included life-style modifications, follow-up visits with physicians and nurses and drug therapy were offered to about 25% of screened subjects.

METHODS

Recruitment costs were generated through out the screening period. Intervention costs were estimated for 5 years after screening. Excess in-patient care costs were estimated by subtracting hospital consumption for an unscreened, matched cohort from that of the screened cohort over follow-up periods of 13-19 years. Intervention and excess in-patient care costs were estimated until 1996.

RESULTS

The net expenditures for recruitment and intervention was SEK253 million and saved costs for in-patient care of SEK143 millions (1998 prices). Considering the opportunity cost of the resources used in the study, the net cost rises to about SEK200 millions.

CONCLUSIONS

The results suggest that only part of the intervention costs were offset by reduction in future morbidity health care costs. This is in line with results from prospective analyses of other primary prevention programmes.

Maximising the uptake of evidence into clinical practice: an information economics approach

Evidence such as systematic reviews or clinical practice guidelines are information products, and clinicians are consumers of those products; their current proliferation but low uptake by consumers indicates an information oversupply. The costs and benefits of accessing and applying information are at least as important as are the costs and benefits of the treatments the information describes. In the same way that a citation index is a measure of the impact of a scientific paper, an evidence uptake index could measure effectiveness of evidence products in a clinical population. The uptake of evidence-based medicine may be hampered by the perceived high cost of changing to it. At present, most costs are borne by individual clinicians, but individual benefits for clinicians are downplayed in favour of population benefits. Specific strategies to increase evidence uptake into practice include decreasing the "cost of ownership"; increasing the direct or perceived value of evidence resources in routine practice; and customising evidence to suit different users, tasks and clinical contexts.

Which clinical practice guidelines for depression? An overview for busy practitioners

BACKGROUND

Many policy and research documents on the treatment of depression in primary care suggest that general practitioners (GPs) should make use of clinical guidelines.

AIM

To describe the content of peer-reviewed guidelines for the detection and treatment of depression in primary care and help GPs identify the one most useful to their own needs.

METHOD

Guidelines were evaluated by an explicit method using the Institute of Medicine assessment instrument and according to six key clinical management questions identified as important by GPs and psychiatrists.

RESULTS

Only five (30%) of the published guidelines identified met all the pre-defined inclusion criteria. Total scores for development process and content ranged from 54% to 82%. Validity scores ranged from 52% to 88%. No guideline answered all the key questions identified by clinicians.

CONCLUSIONS

Only two guidelines conform to the quality standard of a clinical practice guideline. One covers all aspects of detection and management of depression in primary care but gives no advice on first-line choice of antidepressant, while the other focuses only on medication and fails to explore problems of case detection or to consider non-pharmacological treatments. However, taken together they do cover most of the key clinical issues in a reliable and valid manner. The identified guidelines vary considerably in both utility and clinical applicability.

The evidence-based approach in health policy and health care delivery

Evidence-based approaches are prominent on the national and international agendas for health policy and health research. It is unclear what the implications of this approach are for the production and distribution of health in populations, given the notion of multiple determinants in health. It is equally unclear what kind of barriers there are to the adoption of evidence-based approaches in health care practice. This paper sketches some developments in the way in which health policy is informed by the results from health research. It summarises evidence-based approaches in health at three impact levels: intersectoral assessment, national health care policy, and evidence-based medicine in everyday practice. Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases. In spite of methodological constraints, there is a demand for intersectoral assessments, especially in health sector reform. Initiators of policy changes in other sectors may be held responsible for providing the evidence related to health. There are limited possibilities for priority setting at the national health care policy level. Hence, there is a decentralisation of responsibilities for resource use. Health care providers are encouraged to assume agency roles for both patients and society and asked to promote and deliver effective and efficient health care. Governments will have to design a national framework to facilitate their organisation and legal framework to enhance evidence-based health policy. Treatment guidelines supported by evidence on effectiveness and efficiency will be one essential element in this process. With the increasing number of advocates for the enhancement of population health in the policy arenas, evidence-based approaches provide the information and some of the tools to help with priority setting.

Dyspepsia workload in urban general practice and implications of the British Society of Gastroenterology Dyspepsia guidelines (1996)

AIM

To define the characteristics of patients consulting with active dyspeptic symptoms in urban general practice, and to consider the implications of applying the British Society of Gastroenterology Dyspepsia management guidelines.

DESIGN

Prospective observational study over a period of 12 months.

SETTING

Two multipartner, two-centre general practices in the City of Leeds (UK) with a combined target population of 11 011 registered patients.

SUBJECTS

A total of 340 patients consulting with active dyspeptic symptoms (52% male; mean age 53 years, range 16-89 years).

RESULTS

Of the practice population, 3% consulted with dyspepsia (first-time consulter: 19%; previous consulter not yet investigated: 30%; previously investigated: 51%). Of 168 undiagnosed patients, 43% had upper abdominal pain (dysmotility-like symptoms in 42%), 35% had reflux symptoms, 22% had mixed symptoms, 12% had 'alarm' symptoms and 18% had a history of NSAID use. Patients < 45 years old with simple dyspepsia accounted for 32% of undiagnosed cases. A fifth of the workload was in dealing with undiagnosed dyspeptics over 45 years old. One per cent of the population would require endoscopy if all undiagnosed cases either > 45 years or with complicated dyspepsia were investigated. Of 172 previously investigated patients, 29% had negative tests, 25% had 'minor' findings, and 45% had evidence of acid-peptic disease. Patients with duodenal ulcer disease accounted for 12% of the total workload.

CONCLUSIONS

A knowledge of the characteristics of patients consulting with dyspepsia in primary care should allow the adaptation of guidelines, to ensure advice is relevant to local case mix and compatible with local resources.

Suboptimal medical therapy in COPD: exploring the causes and consequences

Effective outpatient management of COPD requires prescription of and adherence to appropriate therapies. Although practice guidelines for outpatient management of COPD are widely available, evidence suggests that these guidelines are not being implemented widely in clinical practice. Furthermore, several studies have shown that patient compliance with recommended therapy is poor. This paper discusses several reasons why implementation of practice guidelines and adherence with prescribed therapies may be poor. Potential clinical and economic consequences of suboptimal management are reviewed. Although the evidence suggests that improved compliance with guideline-recommended practice will improve symptoms and disease-specific quality of life, further work needs to be done to establish the cost-effectiveness of chronic therapies for COPD relative to other chronic conditions. Without such data, managed care organizations will be reluctant to allocate scarce resources toward expensive guideline implementation programs for individuals with this condition.