Using a Clinical Practice Guideline to Measure Physician Practice: Translating a Guideline for the Management of Heart Failure

Background: Effective clinical practice guidelines should improve clinical outcomes, and measures of physician use of clinical practice guidelines should correlate with improved outcomes. This study translates a clinical practice guideline on heart failure into review criteria to measure physician performance and the effectiveness of the clinical practice guideline. Methods: A panel of 11 family physicians and 1 cardiologist systematically reviewed the clinical practice guideline for its clinical importance, educational relevance, and evaluative appropriateness. Then a subset of 4 family physicians rigorously applied each recommendation to established criteria for measurability and developed an evaluation tool useful in medical record review. Results: The heart failure clinical practice guideline was found to be an excellent educational tool. Using it to measure physician performance, however, was limited to diagnostic tests and drug prescribing. Of 45 recommendations, 5 fulfilled criteria for measurability; 1 recommendation had A-level evidence, whereas 2 recommendations had B-level and 2 had C-level evidence. Conclusion: This study illustrates the logistic issues and challenges in developing a measure of physician adherence to clinical practice guidelines. Medical record review is inadequate to measure many recommendations. Physician use of this clinical practice guideline must be evaluated as an intermediate step to measuring the effectiveness of clinical practice guidelines based on patient outcomes. (J Am Board Fam Pract 1997;10:206-12.) Left-ventricular systolic dysfunction, or conges­ tive heart failure (CHF), is a health problem that affects more than 2 million Americans at a cost of more than $10 billion annually. The 5-year mor­ tality rate is about 50 percent for the almost 400,000 new cases diagnosed each year. The mor­ tality rate for CHF patients on angiotensin-con­ verting enzyme (ACE) inhibitors! and for those with angina who undergo coronary artery bypass graft surgery2 has decreased considerably in the last 10 years. Family physicians care for a great percentage of CHF patients and are increasingly under scrutiny for the quality of care rendered to these patients. A survey of practice styles among family physi