Challenges in measuring adherence to clinical practice guidelines.

Family physicians have expressed a broad range of concerns regarding practice guidelines and other clinical policies. These concerns include (but are certainly not limited to) skepticism about the scientific accuracy of recommendations, uneasiness about infringement on autonomy in clinical care, and apprehension regarding potential adverse consequences if wrongly applied by third parties. I-4 But practice guidelines are here to stay, and the wise physician will carefully choose approaches that are well suited to the task of responding appropriately to the panoply of guidelines which daily cross our paths. The options described in Hamlet's familiar soliloquy need not be the only alternatives for responding to practice policies that are less than ideal. The slings and arrows of unacceptable guidelines should not be suffered, nor should we be foolish enough to believe that opposition to the concept of practice guidelines is likely to result in their disappearance. One characteristic in which some practice policies fall short of ideal relates to the practicability of measurement of physician adherence to guidelines. In this issue of the Journal, James and colleagues describe their efforts to address several logistic issues related to measuring adherence to practice guidelines.5 They examine the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline for evaluation and care of patients with heart failure in an attempt to develop review criteria incorporating the perspec-