EVIDENCE-BASED CLINICAL PRACTICE The Use of Balance Sheets in Developing Clinical Guidelines

Improving quality while containing costs is ar-guably the highest priority in health care today. Problems with the quality and cost of care in the United States include wide variations in clinical practice,I-3 medical practices of marginal benefit to patients at increased costs, ineffective prac-tices, and clinical practices initially expected to improve care but that might actually cause harm.4-8 Managed care organizations (MCas) must provide the best available care to their pop-ulations within cost constraints, and clinical guidelines can help achieve this goal. Useful clin-ical guidelines should contain more than clear recommendations. The evidence and reasoning upon which the recommendations are based need to be explicit, and the expected outcomes of implementing the guideline should be stated. Group Health Cooperative of Puget Sound is a large MCa in the Pacific Northwest with a cur-rent enrollment of approximately 600,000 and more than 900 staff physicians and 2500 nonstaff physicians. WIthin this Mea teams of providers with administrative and epidemiologic support have developed 30 evidence-based clinical practice guidelines using an explicit approach to analyze evidence systematically and to project the impacts of each guideline on health care outcomes.9-11 These guidelines are used by providers and pa-tients as an aid to shared decision making, and key outcomes are monitored to check that they have been successfully implemented. Before each guideline reaches its final form, the impacts on all pertinent outcomes (health status, patient satisfac-tion, provider satisfaction, cost and utilization, and capital needs) are determined by developing a balance sheet. 10,11 The balance sheet in clinical guideline develop