# Medical guideline

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Document with the aim of guiding decisions and criteria in healthcare

Not to be confused with [Clinical pathway](/source/Clinical_pathway).

Plates vi & vii of the [Edwin Smith Papyrus](/source/Edwin_Smith_Papyrus) (around the 17th century BC), among the earliest medical guidelines

A **medical guideline** (also called a **clinical guideline**, **standard treatment guideline**, or **clinical practice guideline**) is a [document](/source/Document) with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of [healthcare](/source/Healthcare). Such documents have been in use for thousands of years during the entire [history of medicine](/source/History_of_medicine). However, in contrast to previous approaches, which were often based on tradition or authority, modern medical guidelines are based on an examination of current evidence within the paradigm of [evidence-based medicine](/source/Evidence-based_medicine).[1][2][3] They usually include summarized [consensus statements](/source/Consensus_(medical)) on best practice in [healthcare](/source/Healthcare). A healthcare provider is obliged to know the medical guidelines of their profession, and has to decide whether to follow the recommendations of a guideline for an individual treatment.[4]

## Background

Modern clinical guidelines identify, summarize and evaluate the highest quality evidence and most current data about [prevention](/source/Preventive_medicine), [diagnosis](/source/Diagnosis), [prognosis](/source/Prognosis), therapy including dosage of medications, [risk/benefit](/source/Risk-benefit_analysis) and [cost-effectiveness](/source/Cost-effectiveness). Then they define the most important questions related to clinical practice and identify all possible [decision options](/source/Decision-making) and their [outcomes](/source/Upside_outcomes). Some guidelines contain decision or computation [algorithms](/source/Algorithm_(medical)) to be followed. Thus, they integrate the identified decision points and respective courses of action with the [clinical judgement](/source/Clinical_judgement) and experience of practitioners. Many guidelines place the treatment alternatives into classes to help providers in deciding which treatment to use.

Additional objectives of clinical guidelines are to [standardize](/source/Standardization) medical care, to raise quality of care, to reduce several kinds of risk (to the patient, to the healthcare provider, to [medical insurers](/source/Medical_insurance) and health plans) and to achieve the best balance between cost and medical parameters such as [effectiveness](/source/Effectiveness), [specificity](/source/Specificity_(tests)), [sensitivity](/source/Sensitivity_(tests)), resoluteness, etc. It has been demonstrated repeatedly that the use of guidelines by healthcare providers such as [hospitals](/source/Hospitals) is an effective way of achieving the objectives listed above, although they are not the only ones.

## Publication

Guidelines are usually produced at national or international levels by medical associations or governmental bodies, such as the United States [Agency for Healthcare Research and Quality](/source/Agency_for_Healthcare_Research_and_Quality). Local healthcare providers may produce their own set of guidelines or adapt them from existing top-level guidelines. Healthcare payers such as insurers practicing [utilization management](/source/Utilization_management) also publish guidelines.[5]

Special [computer software](/source/Computer_software) packages known as [guideline execution engines](/source/Guideline_execution_engine) have been developed to facilitate the use of medical guidelines in concert with an [electronic medical record](/source/Electronic_medical_record) system. The [Guideline Interchange Format](/source/Guideline_Interchange_Format) (GLIF) is a computer representation format for clinical guidelines that can be used with such engines.[6]

The US and other countries maintain medical guideline [clearinghouses](https://en.wiktionary.org/wiki/clearing_house). In the US, the [National Guideline Clearinghouse](/source/National_Guideline_Clearinghouse) maintains a catalog of high-quality guidelines published by various health and medical associations. In the [United Kingdom](/source/United_Kingdom), clinical practice guidelines are published primarily by the [National Institute for Health and Care Excellence](/source/National_Institute_for_Health_and_Care_Excellence) (NICE). In The [Netherlands](/source/Netherlands), two bodies—the [Institute for Healthcare Improvement](https://nl.wikipedia.org/wiki/Centraal_BegeleidingsOrgaan) (CBO) and [College of General Practitioners](https://nl.wikipedia.org/wiki/Nederlands_Huisartsen_Genootschap) (NHG)—have published specialist and primary care guidelines, respectively. In [Germany](/source/Germany), the [German Agency for Quality in Medicine](/source/German_Agency_for_Quality_in_Medicine) (ÄZQ) coordinates a national program for disease management guidelines. All these organisations are now members of the [Guidelines International Network](/source/Guidelines_International_Network) (G-I-N), an international network of organisations and individuals involved in clinical practice guidelines.

## Compliance

*[The New York Times](/source/The_New_York_Times)* reported in 2004 that some simple clinical practice guidelines are not routinely followed to the extent they might be.[7] It has been found that providing a [nurse](/source/Nurse) or other medical assistant with a [checklist](/source/Checklist) of recommended procedures can result in the attending physician being reminded in a timely manner regarding procedures that might have been overlooked.

[Checklists](/source/Checklists) have been used in medical practice to attempt to ensure that clinical practice guidelines are followed. An example is the Surgical Safety Checklist developed for the [World Health Organization](/source/World_Health_Organization) by [Atul Gawande](/source/Atul_Gawande).[8] According to a meta-analysis after introduction of the checklist mortality dropped by 23% and all complications by 40%, but further high-quality studies are required to make the meta-analysis more robust.[9] In the UK, a study on the implementation of a checklist for provision of medical care to elderly patients admitting to hospital found that the checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices, but that work is needed to understand whether and how checklists can be embedded in complex multidisciplinary care.[10]

## Problems

### Quality

Guidelines may have both methodological problems and conflict of interest.[11] As such, the quality of guidelines may vary substantially,[12] especially for guidelines that are published online and have not had to follow methodological reporting standards often required by reputable clearinghouses.[13]

Guidelines may make recommendations that are stronger than the supporting evidence.[14]

### Exclusion of non-expert stakeholders

Patients and caregivers are frequently excluded from clinical guidelines development, in part because there is a lack of guidance for how to include them in the process.[15]

### Timeliness

Guidelines may lose their clinical relevance as they age and newer research emerges.[16] Even 20% of strong recommendations, especially when based on opinion rather than trials, from practice guidelines may be retracted.[17]

In response to many of the problems with traditional guidelines, the BMJ created a new series of trustworthy guidelines focused on the most pressing medical issues called *BMJ* Rapid Recommendations.[18]

## Examples

- The [American Heart Association](/source/American_Heart_Association) Guidelines for the [Prevention](/source/Dental_antibiotic_prophylaxis) of [Infective Endocarditis](/source/Infective_endocarditis)[19]

- [BMJ Rapid Recommendations](/source/BMJ_Rapid_Recommendations)[18] guideline on [transcatheter aortic valve implantation](/source/Transcatheter_aortic_valve_implantation) versus surgical [aortic valve replacement](/source/Aortic_valve_replacement) for [aortic stenosis](/source/Aortic_stenosis)[20]

- [Maudsley Prescribing Guidelines](/source/Maudsley_Prescribing_Guidelines)

- [WHO SMART guidelines](/source/WHO_SMART_guidelines)

## See also

- [Clinical formulation](/source/Clinical_formulation)

- [Clinical prediction rule](/source/Clinical_prediction_rule)

- [Clinical trial protocol](/source/Clinical_trial_protocol)

- [Medical algorithm](/source/Medical_algorithm)

- *[The Medical Letter on Drugs and Therapeutics](/source/The_Medical_Letter_on_Drugs_and_Therapeutics)*

## References

1. **[^](#cite_ref-1)** Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J (2003). ["Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs"](https://doi.org/10.1093%2Fintqhc%2F15.1.31). *Int J Qual Health Care*. **15** (1): 31–45. [doi](/source/Doi_(identifier)):[10.1093/intqhc/15.1.31](https://doi.org/10.1093%2Fintqhc%2F15.1.31). [PMID](/source/PMID_(identifier)) [12630799](https://pubmed.ncbi.nlm.nih.gov/12630799).

1. **[^](#cite_ref-2)** AGREE Collaboration (2003). ["Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743672). *Qual Saf Health Care*. **12** (1): 18–23. [doi](/source/Doi_(identifier)):[10.1136/qhc.12.1.18](https://doi.org/10.1136%2Fqhc.12.1.18). [PMC](/source/PMC_(identifier)) [1743672](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743672). [PMID](/source/PMID_(identifier)) [12571340](https://pubmed.ncbi.nlm.nih.gov/12571340).

1. **[^](#cite_ref-3)** Institute of Medicine (edt.) [Clinical practice guidelines we can trust](http://books.nap.edu/openbook.php?record_id=13058). Washington DC, 2011

1. **[^](#cite_ref-4)** Council of Europe. [Developing a methodology for drawing up guidelines on best medical practice. Recommendation Rec(2001)13 and explanatory memorandum. Strasbourg: Council of Europe Publishing, 2002.](http://www.leitlinien.de/mdb/edocs/pdf/literatur/coe-rec-2001-13.pdf)

1. **[^](#cite_ref-5)** Moses, Richard E.; Feld, Andrew D. (2008-01-01). "Legal risks of clinical practice guidelines". *The American Journal of Gastroenterology*. **103** (1): 7–11. [doi](/source/Doi_(identifier)):[10.1111/j.1572-0241.2007.01399.x](https://doi.org/10.1111%2Fj.1572-0241.2007.01399.x). [ISSN](/source/ISSN_(identifier)) [0002-9270](https://search.worldcat.org/issn/0002-9270). [PMID](/source/PMID_(identifier)) [18184116](https://pubmed.ncbi.nlm.nih.gov/18184116). [S2CID](/source/S2CID_(identifier)) [11802118](https://api.semanticscholar.org/CorpusID:11802118).

1. **[^](#cite_ref-6)** [GLIF website](http://www.openclinical.org/gmm_glif.html)

1. **[^](#cite_ref-7)** [Gina Kolata](/source/Gina_Kolata) "[Program Coaxes Hospitals to See Treatments Under Their Noses](https://www.nytimes.com/2004/12/25/health/25medicine.html)". *[The New York Times](/source/The_New_York_Times)* December 25, 2004.

1. **[^](#cite_ref-8)** Haynes, Alex B.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen; Herbosa, Teodoro; Joseph, Sudhir; Kibatala, Pascience L.; Lapitan, Marie Carmela M.; Merry, Alan F.; Moorthy, Krishna; Reznick, Richard K.; Taylor, Bryce; Gawande, Atul A. (29 January 2009). ["A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population"](https://dash.harvard.edu/bitstream/1/38846186/1/Gawande_Surgical%20Safety%20Checklist%20to%20Reduce%20Morbidity%20vor.pdf) (PDF). *New England Journal of Medicine*. **360** (5): 491–499. [doi](/source/Doi_(identifier)):[10.1056/NEJMsa0810119](https://doi.org/10.1056%2FNEJMsa0810119). [PMID](/source/PMID_(identifier)) [19144931](https://pubmed.ncbi.nlm.nih.gov/19144931). [S2CID](/source/S2CID_(identifier)) [2639397](https://api.semanticscholar.org/CorpusID:2639397).

1. **[^](#cite_ref-9)** Bergs, J.; Hellings, J.; Cleemput, I.; Zurel, Ö.; De Troyer, V.; Van Hiel, M.; Demeere, J.-L.; Claeys, D.; Vandijck, D. (February 2014). ["Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications"](https://doi.org/10.1002%2Fbjs.9381). *British Journal of Surgery*. **101** (3): 150–158. [doi](/source/Doi_(identifier)):[10.1002/bjs.9381](https://doi.org/10.1002%2Fbjs.9381). [PMID](/source/PMID_(identifier)) [24469615](https://pubmed.ncbi.nlm.nih.gov/24469615). [S2CID](/source/S2CID_(identifier)) [22951117](https://api.semanticscholar.org/CorpusID:22951117).

1. **[^](#cite_ref-10)** Papoutsi, Chrysanthi; Poots, Alan; Clements, Jake; Wyrko, Zoe; Offord, Natalie; Reed, Julie E (5 January 2018). ["Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016694). *Age and Ageing*. **47** (2): 311–317. [doi](/source/Doi_(identifier)):[10.1093/ageing/afx194](https://doi.org/10.1093%2Fageing%2Fafx194). [PMC](/source/PMC_(identifier)) [6016694](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016694). [PMID](/source/PMID_(identifier)) [29315375](https://pubmed.ncbi.nlm.nih.gov/29315375).

1. **[^](#cite_ref-pmid23752105_11-0)** Reames BN; Krell RW; Ponto SN; Wong SL (2013). ["Critical evaluation of oncology clinical practice guidelines"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073383). *J Clin Oncol*. **31** (20): 2563–8. [doi](/source/Doi_(identifier)):[10.1200/JCO.2012.46.8371](https://doi.org/10.1200%2FJCO.2012.46.8371). [PMC](/source/PMC_(identifier)) [5073383](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073383). [PMID](/source/PMID_(identifier)) [23752105](https://pubmed.ncbi.nlm.nih.gov/23752105).

1. **[^](#cite_ref-12)** Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, for the AGREE Next Steps Consortium. [AGREE II: Advancing guideline development, reporting and evaluation in healthcare](https://www.agreetrust.org/wp-content/uploads/2017/12/AGREE-II-Users-Manual-and-23-item-Instrument-2009-Update-2017.pdf). *[Canadian Medical Association Journal](/source/Canadian_Medical_Association_Journal)* 2010;182:E839-842 (2017 update).

1. **[^](#cite_ref-13)** Norberg MM, Turner MW, Rooke SE, Langton JM, Gates PJ (2012). ["An Evaluation of Web-Based Clinical Practice Guidelines for Managing Problems Associated with Cannabis Use"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799569). *J Med Internet Res*. **14** (6): e169. [doi](/source/Doi_(identifier)):[10.2196/jmir.2319](https://doi.org/10.2196%2Fjmir.2319). [PMC](/source/PMC_(identifier)) [3799569](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799569). [PMID](/source/PMID_(identifier)) [23249447](https://pubmed.ncbi.nlm.nih.gov/23249447).

1. **[^](#cite_ref-pmid23783104_14-0)** Brito JP; Domecq JP; Murad MH; Guyatt GH; et al. (2013). ["The Endocrine Society guidelines: when the confidence cart goes before the evidence horse"](https://doi.org/10.1210%2Fjc.2013-1814). *J Clin Endocrinol Metab*. **98** (8): 3246–52. [doi](/source/Doi_(identifier)):[10.1210/jc.2013-1814](https://doi.org/10.1210%2Fjc.2013-1814). [PMID](/source/PMID_(identifier)) [23783104](https://pubmed.ncbi.nlm.nih.gov/23783104).

1. **[^](#cite_ref-15)** Khodyakov, Dmitry; Kinnett, Kathi; Grant, Sean; Lucas, Ann; Martin, Ann; Denger, Brian; Peay, Holly; Coulter, Ian; Fink, Arlene (2017-04-28). ["Engaging Patients and Caregivers Managing Rare Diseases to Improve the Methods of Clinical Guideline Development: A Research Protocol"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429434). *JMIR Research Protocols*. **6** (4): e57. [doi](/source/Doi_(identifier)):[10.2196/resprot.6902](https://doi.org/10.2196%2Fresprot.6902). [ISSN](/source/ISSN_(identifier)) [1929-0748](https://search.worldcat.org/issn/1929-0748). [PMC](/source/PMC_(identifier)) [5429434](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429434). [PMID](/source/PMID_(identifier)) [28455279](https://pubmed.ncbi.nlm.nih.gov/28455279).

1. **[^](#cite_ref-pmid11572738_16-0)** Shekelle PG; Ortiz E; Rhodes S; et al. (2001). ["Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated?"](https://doi.org/10.1001%2Fjama.286.12.1461). *JAMA*. **286** (12): 1461–7. [doi](/source/Doi_(identifier)):[10.1001/jama.286.12.1461](https://doi.org/10.1001%2Fjama.286.12.1461). [PMID](/source/PMID_(identifier)) [11572738](https://pubmed.ncbi.nlm.nih.gov/11572738).

1. **[^](#cite_ref-pmid24867012_17-0)** Neuman MD; Goldstein JN; Cirullo MA; Schwartz JS (2014). ["Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations"](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346183). *JAMA*. **311** (20): 2092–100. [doi](/source/Doi_(identifier)):[10.1001/jama.2014.4949](https://doi.org/10.1001%2Fjama.2014.4949). [PMC](/source/PMC_(identifier)) [4346183](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346183). [PMID](/source/PMID_(identifier)) [24867012](https://pubmed.ncbi.nlm.nih.gov/24867012).

1. ^ [***a***](#cite_ref-siemieniuk1_18-0) [***b***](#cite_ref-siemieniuk1_18-1) Siemieniuk, Reed A; Agoritsas, Thomas; Macdonald, Helen; Guyatt, Gordon H; Brandt, Linn; Vandvik, Per O (28 September 2016). "Introduction to BMJ Rapid Recommendations". *BMJ*. **354** i5191. [doi](/source/Doi_(identifier)):[10.1136/bmj.i5191](https://doi.org/10.1136%2Fbmj.i5191). [ISSN](/source/ISSN_(identifier)) [1756-1833](https://search.worldcat.org/issn/1756-1833). [PMID](/source/PMID_(identifier)) [27680768](https://pubmed.ncbi.nlm.nih.gov/27680768). [S2CID](/source/S2CID_(identifier)) [32498374](https://api.semanticscholar.org/CorpusID:32498374).

1. **[^](#cite_ref-19)** Wilson W; Taubert KA; Gewitz M; et al. (October 2007). ["Prevention of infective endocarditis: guidelines from the American Heart Association"](http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=17446442). *Circulation*. **116** (15): 1736–54. [doi](/source/Doi_(identifier)):[10.1161/CIRCULATIONAHA.106.183095](https://doi.org/10.1161%2FCIRCULATIONAHA.106.183095). [PMID](/source/PMID_(identifier)) [17446442](https://pubmed.ncbi.nlm.nih.gov/17446442).

1. **[^](#cite_ref-vandvik_20-0)** Vandvik PO, Otto CM, Siemieniuk RA, Bagur R, Guyatt GH, Lytvyn L, Whitlock R, Vartdal T, Brieger D, Aertgeerts B, Price S, Foroutan F, Shapiro M, Mertz R, Spencer FA (2016). ["Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline"](http://www.bmj.com/content/354/bmj.i5085.long). *BMJ*. **354** i5085. [doi](/source/Doi_(identifier)):[10.1136/bmj.i5085](https://doi.org/10.1136%2Fbmj.i5085). [PMID](/source/PMID_(identifier)) [27680583](https://pubmed.ncbi.nlm.nih.gov/27680583).

## External links

- [British Columbia Medical Guidelines](http://www.bcguidelines.ca) – In Canada, British Columbia's guidelines and protocols are developed under the direction of the Guidelines and Protocols Advisory Committee (GPAC), jointly sponsored by the B.C. Medical Association and the B.C. Ministry of Health Services.

- [The Cochrane Collaboration](http://www.cochrane.org/) – An international, independent, not-for-profit organisation of over 27,000 contributors from more than 100 countries, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide.

- [GuiaSalud. Clinical Practice Guidelines for the National Health System (Spain)](https://web.archive.org/web/20151222093955/http://www.guiasalud.es/web/guest/gpc-sns) – Contains clinical practice guidelines developed in Spain translated into English.

- [Guideline Elements Model](https://web.archive.org/web/20160303174800/http://gem.med.yale.edu/) – The Guideline Elements Model (GEM) is an ASTM standard for the representation of practice guidelines in XML format.

- [Guideline Interchange Format](http://mis.hevra.haifa.ac.il/~morpeleg/Intermed/) – The [Guideline Interchange Format](/source/Guideline_Interchange_Format) (GLIF) is a specification for structured representation of guidelines.

- [Guidelines International Network](http://www.g-i-n.net) – Contains the largest online guideline library.

- [Hospital Quality Alliance](http://www.hospitalqualityalliance.org/) – A project of the Hospital Quality Initiative (HQI) of the Centers for Medicare and Medicaid Services (USA).

- [National Guideline Clearinghouse](https://web.archive.org/web/20140819030216/http://www.guideline.gov/) (NGC) – A public resource for evidence-based clinical practice guidelines. NGC is an initiative of the [Agency for Healthcare Research and Quality](/source/Agency_for_Healthcare_Research_and_Quality) (AHRQ), [U.S. Department of Health and Human Services](/source/U.S._Department_of_Health_and_Human_Services).

- [Scottish Intercollegiate Guidelines Network (SIGN)](http://www.sign.ac.uk) – Contains 113 evidence-based clinical guidelines – published, in development, or under review.

- [German guidelines (AWMF)](http://www.awmf.org/leitlinien/aktuelle-leitlinien.html) – A collection of current German health care-related professional associations' guidelines.

v t e Clinical governance Theory Clinical governance Health administration Organisations Health minister Health department List of health departments and ministries Metrics Never events Length of stay Cost per procedure Waiting in healthcare Practice Clinical audit Medical guideline Medical strikes

v t e Health care quality Concepts of quality Evidence-based medicine Medical consensus Medical guideline Health care evaluations Clinical audit Clinical peer review Independent medical review Health care ratings Health impact assessment Health services research Routine health outcomes measurement Routine outcome measurement Accreditation Hospital accreditation International healthcare accreditation List of international healthcare accreditation organizations Costs and benefits Health economics Health care efficiency Health care rationing Incremental cost-effectiveness ratio Cost-effectiveness analysis Cost-minimization analysis Cost–utility analysis Cost per procedure Value of life Tools Clinical Quality Management System Disability-adjusted life year Healthy Life Years Health Utilities Index Quality-adjusted life year

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Adapted from the Wikipedia article [Medical guideline](https://en.wikipedia.org/wiki/Medical_guideline) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Medical_guideline?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.