The overarching challenge.

M ore than 15 years ago, the public awoke to newspaper headlines that Medicare had released survival data from their administrative data base for patients undergoing cardiac surgery in American hospitals. The statistics indicated the existence of marked differences in mortality rates among similar facilities. The reporting of these data initiated immediate changes in referral patterns and program design in many health care facilities. As we later learned however, the risk-unadjusted data had misrepresented surgical results. Nevertheless, the newspaper reports signaled the beginning of a public dialogue regarding the variations—in practice, costs, and outcomes—that existed across the American health care system. During the ensuing years, the quality and cost of health care have become major concerns of the medical profession, the public, third-party payers, and multiple local, state, and federal regulatory agencies. These concerns have spawned health services research studies that have demonstrated shortcomings in our health care system, including regional variations in medical practices,1 inappropriate use of medical interventions,2 and early adoption of new technologies before effectiveness has been established.3 There has been no shortage of attempted solutions to these problems. Physicians have experienced peer review organizations, mandatory continuing medical education requirements, professional board recertification, and treatment preauthoraization, to name a few. Although these interventions have varied in effectiveness and rationality of design, they hold in common the recognition that physician decisions not only influence the health of their patients but also determine the cost of their care. It follows that the ability to influence physicians’ practices could improve the quality of care while controlling health care expenditures.4 Managed care represents the institutionalization of strategies to establish influenced care. Faced with political and economic influences to control costs and alter their practices, physicians have become increasingly challenged to maintain professional standards of care and to shape this new health care environment for the benefit of their patients and their profession. The explosion of medical knowledge has not simplified this challenge. It has been estimated that more than 33,000 citations are added to MEDLINE each month. In an era of greater scrutiny and accountability, the ability of physicians to update their medical knowledge and to place newly acquired information in context with existing knowledge to improve clinical practice has been sorely stressed.5 This is the health care environment in which the American College of Chest Physicians (ACCP) began to develop and promote clinical practice guidelines (CPGs) more than 15 years ago. Practice guidelines represent the interests of professional societies to identify best current practices of care, to educate physicians, and to improve health care delivery. The premise of CPGs lies in evidence-based medicine, which is ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. ‘6 Guidelines themselves have been defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. ‘7 In operational terms, CPGs discourage ineffective medical practices and encourage effective care in order to improve health outcomes.8–13 In strategic terms, guidelines provide the necessary evidence-based data to empower clinicians to make informed decisions and to counter managerial influences to alter their practices in ways that may not be in the best interests of their patients. Although guidelines have been identified as having lineage in traditional medical writings,11 they have a uniqueness all their own in presenting coherently sequenced recommendations that link specific information sources with specific information uses.14 What CPGs do not represent is cookbook medicine. Clinical guidelines summarize recent knowledge in a manner that encourages flexible application of recommendations to the unique clinical problems of individual patients. Guidelines are the substrate for experienced clinicians who interpret science with an intention to practice the art of medicine for the benefit of the individual patients. Despite more than a decade of productive guideline development, however, the ACCP has reason to pause and reflect on the value of commissioning new guidelines in *From the Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina. Correspondence to: John E. Heffner, MD, FCOP, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 812, PO Box 250623, Charleston, SC 29425; e-mail: heffnerj@musc.edu CHEST