POLICY PAPER

CLINICAL

PRACTICE

GUIDELINES:

OPPORTUNITIES

AND IMPLICATIONS

~

Margaret Edmunds, Ph.D. University of California, San Francisco

ABSTRACT

issues, such as payment mechanisms for services purchased with Federal funds, primarily Medicare and Medicaid. Research on quality of care was underfunded, and most standards of care were set by the private sector through professional associations and through autonomous decisions by individual practitioners (usually physicians) and by state licensing boards. Now, Federal policy is turning more toward prevention, based on a long-term strategy to shift resources into primary care, population-based health promotion activities, and disease prevention through risk assessment and screening (1). By definition, preventive strategies highlight the importance of personal health practices, health behaviors, and self-care activities (2). Some of the most effective clinical strategies for reducing the incidence and severity of illness and disability are aimed at behavioral risk factors, such as physical inactivity, poor nutrition, and the use of alcohol, tobacco, and other drugs (3,4). Yet, these behavioral domains have been described as the central challenge for the health policy agenda and also for the larger public policy agenda (5). From a policy perspective, the search for effective incentives to change individual and group behaviors in desirable directions raises core public policy questions. What should be the role of government in influencing an individual's behavior, especially when that behavior puts the individual and others at risk? What existing evidence on the effectiveness of behavioral interventions can be used in setting priorities for the distribution of public funds and other resources? Who should be involved in setting priorities and maintaining accountability of health care delivery systems? Clinical practice guidelines have been endorsed by policymakers as a key activity in rationalizing decision-making about the delivery of health care. In its 1989 report to Congress, the Physician Payment Review Commission (PPRC) recommended substantial increases in Federal funding for outcomes research and for the development, implementation, and evaluation of practice guidelines (6). In that same year, Congress passed legislation creating a new agency in the Public Health Service (PHS), the Agency for Health Care Policy and Research (AHCPR), to carry out those responsibilities (7). The purposes of this article are to describe the general process of development of practice guidelines, using models developed by AHCPR and other sources; to describe some of the barriers to comprehensive guideline development and implementation; and to suggest ways in which behavioral knowledge and intervention strategies can contribute to health policy decisions through the development, implementation, and evaluation of guidelines to improve health status and the quality of care.

Clinical practice guidelines have been defined as systematica[ly developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They are intended to improve the quality, appropriateness, and effectiveness of care. While particular guidelines may be challenged on the grounds that they are not inclusive of all effective treatment strategies or are too difficult or too expensive to implement, there is evidence that guidelines can influence clinical decision-making in ways that improve treatment outcomes and sometimes also in ways that reduce costs. Guidelines are viewed by policymakers as an important factor in rational decision-making about payment practices and other policy issues, but they can provoke controversies among providers and researchers. This article gives a broad overview of practice guidelines from a health policy perspective. Strategies for guideline development are described, with a focus on guidelines developed by the Agency for Health Care Policy and Research, the U.S. Clinical Preventive Services Task Force, and managed care organizations. Issues related to implementation of guidelines are discussed, including the need to reach agreement on the standards of evidence for clinical effectiveness. Strategies are discussed for increasing the application of behavioral research findings for multicomponent treatment and population-based preventive interventions. (Ann Behav Med

1996, 18(2):126-132)

INTRODUCTION: THE POLICY CONTEXT Health policy is a field within public health that is concerned with the management, organization, delivery, and financing of health systems. Until the recent past, the development of health policy at the national level focused on regulatory J The author acknowledges thoughtful comments and suggestions from the following individuals: David Altman, Erica Frank, Pat Franks, Jessie Gruman, Jeff Harris, Abby King, Rick Kunnes, Barbara Lamb, Hal Luft, Mike Parkinson, Helen Schauffier, Daniel Shostak, Dennis Turk, Marcia Ward, and Steve Weiss. Reprint Address: M. Edmunds, Ph.D., Institute of Medicine, National Academy of Sciences, 2101 Constitution Avenue NW, Washington, DC 20418. 9 1996 by The Society of Behavioral Medicine.

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Clinical Practice Guidelines C L I N I C A L P R A C T I C E G U I D E L I N E S : T H E M E S AND VARIATIONS Clinical practice guidelines have been defined by the Institute of Medicine as systematically developed statements to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances (8). Guidelines and other recommendations, such as consensus statements, have been developed by medical specialty organizations, by Federal agencies, by professional and scientific organizations, and by voluntary associations. They have been used to help guide clinicians in decision-making, to assist institutions in developing their own clinical risk management protocols, to guide payers in setting reimbursement policies, and, more recently, to assist consumers in promoting health and choosing appropriate care (9-12). The earliest national guidelines by a professional organization were issued in the 1950s by the American Academy of Pediatrics (AAP), using an expert consensus process. A panel of experts reviewed evidence that pediatricians were underutilizing effective vaccines and administering others inappropriately; they then developed guidelines on effective immunization practices and publicized them in a national information campaign (13). The consensus process is still used in guideline development by many organizations, including the National Institutes of Health (NIH). The American Medical Association (AMA) Council on Scientific Affairs uses expert opinions as well as literature reviews to develop its guidelines and policy statements (14,15). The first professional organization to relate guidelines to reimbursement was the American College of Physicians (ACP), the major professional organization for internal medicine. In the mid-1970s, the ACP developed a partnership with the Blue Cross and Blue Shield Associations to review the efficacy of a large number of diagnostic tests and to determine the cost and quality implications of unnecessary testing. Experts developed a consensus on which ineffective and outmoded tests should be replaced, and the findings were used as the basis for reimbursement policies on laboratory tests, saving several million dollars (13). When the quality movement swept American businesses and industry in the mid-1980s, medical administrators began to adapt the concepts of performance measures and outcome assessments to clinical care. Thus, guidelines were used primarily as management tools for decisions about precertification, quality assurance, and utilization review (12). Currently, guidelines developed by a Seattle-based consulting firm, Milliman & Robertson, Inc., are used by health plans at Prudential, Cigna, U.S. Healthcare, Kaiser Permanente, and many Blue Cross and Blue Shield plans, affecting a combined total of 50 million members, subscribers, or covered lives. The Harvard Pilgrim Health Plan is currently evaluating the impact of the Milliman & Robertson guidelines on cost and quality of care, and the findings are expected to influence treatment and training at major teaching hospitals and elsewhere (16). Approximately 1,600 guidelines from 45 national medical groups and several other organizations are listed in the directory of guidelines published by the American Medical Association (17). In the managed care sector, hundreds of proprietary guidelines have also been developed. Thus, it is not uncommon to have conflicting recommendations, varying degrees of involvement by clinicians in their development, and varying amounts

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of supporting evidence from research. Experience shows that some guidelines are cost-saving, by improving care coordination and eliminating unnecessary and ineffective procedures. Other guidelines can increase costs by recommending additional services and procedures. From a policy perspective, there is no hope of spending the money or the time required to develop practice guidelines based on randomized controlled trials for every medical condition. Yet, accountability for public funds requires some rational basis to evaluate the quality and effectiveness of care and the cost implications for different treatment strategies. Guidelines are viewed by policymakers as a way to "synthesize the best that we know from research and the judgments of practicing physicians into a form that can be readily used" (6, p. 21), thus applying the best available evidence in order to make more informed and rational policy decisions. D E V E L O P M E N T OF G U I D E L I N E S

Agency for Health Care Policy and Research

The Legislative Mandate: In the mid-1980s, Congress became aware of significant variations in patterns of medical practice with no rational, scientific, or clinical basis. Several studies by Wennberg of Dartmouth University had revealed substantial geographic differences in practice styles, such as differences in the rates of tonsillectomies, hysterectomies, and other common surgical procedures (18). Researchers at the RAND Corporation were studying variations in patterns of practice across medical specialties and practice settings (19-21). As a major purchaser of health care, the Federal government could not justify spending taxpayers' money on unnecessary or ineffective procedures, but there was very little rigorous research on the effectiveness of most health services. At the time, funding for health services research was in the range of $20 million, compared with $6 billion for biomedical research at the National Institutes of Health. The Physician Payment Review Commission, the Health Care Financing Administration, Federal research agencies such as the Office of Technology Assessment and General Accounting Office, and the Association for Health Services Research had all recommended increases in Federal support for outcomes research (7,22). There was a bipartisan convergence of views that a national data base was needed for decision-making based on programmatic research on clinical outcomes (7). The legislative language creating AHCPR consisted of just 20 pages in the nearly 400-page Omnibus Budget Reconciliation Act (OBRA) of 1989, which was best known for its targets to reduce the deficit (7). AHCPR embodied a Federal commitment to support outcomes and effectiveness research, addressing issues related to treatment, medical technologies, and prevention. The agency was designed to promote the use of evidence-based clinical decision-making through development of practice guidelines for use by practitioners, payers, and patients. The AHCPR budget for Fiscal Year 1994 was $154 million (23), a significant but relatively small amount considering that health care systems involve one-seventh of the American economy. Development of AHCPR Guidelines: AHCPR uses several criteria in setting priorities for the development of guidelines (24). The primary factor is the estimated potential for reducing unexplained and clinically significant variations in services and procedures used in the diagnosis, treatment, management, or

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outcomes of treatment for a given condition. Preventable conditions are also given higher priority, which means behavioral interventions are appropriately considered in the evidence base. Large numbers of individuals must be affected, and there must be an adequate amount of research to systematically evaluate different treatment strategies and outcomes for different populations. Cost implications of various treatments are taken into consideration (24). Congress also specified that the needs of women, children, ethnic minorities, and other underserved and special populations were a high priority (25). The methodology for AHCPR guidelines was developed with assistance from the Institute of Medicine and several other experts (8,24). Multidisciplinary, private-sector panels with approximately 15 experts and consumers are convened, including a variety of primary and specialty physicians, nurses, psychologists, and other providers who are involved in treating the condition of interest in a variety of settings. As with other PHS agencies, AHCPR panel participation must be balanced in terms of professions and gender, be racially and ethnically diverse, and come from a variety of geographic areas. When combined with the need for appropriate academic and professional expertise, previous experience in guideline development, and other selection criteria, the panels are chosen from a small and highly select group of individuals. The guideline development process involves specific steps. Once the research questions are defined, available scientific research is analyzed to determine benefits and harms of each intervention. Costs associated with a guideline are reviewed and estimated for alternative strategies for the prevention, diagnosis, treatment, and management of the condition. Algorithms are developed to note the standard steps or pathways in clinical decision-making about the condition. Once a guideline is developed, comments are invited from professional and consumer organizations, researchers, industry, and others through publication of a notice in the Federal Register and through direct mail. An open meeting is held to invite public comments on the guideline. After the review and revisions, the guideline is distributed in a variety of formats, including provider and consumer versions. Publicity is generated through newspaper articles and professional presentations, and a toll-free number is available to request free copies. Copies are also mailed to professional organizations, education and accreditation organizations, insurance companies, consumer groups, and many other groups and described in a free bimonthly newsletter and electronic data bases. AHCPR has research programs to evaluate the effects of its guidelines. Different strategies for dissemination and implementation are being studied, and evaluations are being made of provider behavior changes when specific guidelines are introduced in several practice settings. AHCPR also has two large programs for medical effectiveness research. Patient Outcomes Research Teams (PORTs) conduct large-scale, multidisciplinary evaluations of variations in medical practice and patient outcomes for a particular condition, such as low back pain, hysterectomy, or breast cancer. The Medical Treatment Effectiveness Program (MEDTEP) funds multidisciplinary research on non-clinical variables associated with the structure, processes, and outcomes of health care (26). Research findings are expected to be widely disseminated to professional audiences and the public through scientific articles, interviews with the press, and electronic data bases.

Edmunds AHCPR guidelines have been developed for acute pain management, cancer pain, benign prostatic hyperplasia, depression in primary care, sickle cell disease, low back pain, mammography, HIV/AIDS, urinary incontinence, cataracts, unstable angina, and other conditions. Several others are in development; the cost is approximately $1 million for each guideline. The main provider audience for guidelines is primary care practitioners, but, depending on the nature of the problem, the professional composition of the panel, and the research base, behavioral interventions are also included in the reviews. For example, the depression guideline reviewed evidence from effectiveness research with behavior therapy, cognitive therapy, marital therapy, and other forms of psychotherapy and made recommendations about medical management with and without medication. Consultations and referrals to mental health professionals were presented as options, although it was suggested that waiting lists might be a problem and the primary care practitioner may need to continue medical management in the interim (27). The U.S. Preventive Services Task Force The U.S. Preventive Services Task Force was commissioned in 1984 by the Assistant Secretary for Health to develop national guidelines for preventive interventions, including screening tests, counseling interventions, and immunizations/chemoprophylaxis. The Task Force consists of 20 nonFederal experts in primary care medicine, clinical epidemiology, public health, dentistry, nursing, health services research, health education, health economics, and medical sociology. In choosing studies for inclusion in its review, the Task Force and its scientific staff at the Office of Disease Prevention and Health Promotion (ODPHP) developed specific criteria or "rules of evidence" to evaluate each service or procedure being considered. Greatest weight was given to evidence from randomized controlled trials, followed by non-randomized controlled trials, cohort studies, case-control studies, comparisons between time or places, uncontrolled experimental descriptive studies, and expert opinion (3). The Task Force and the scientific staff at the Office of Disease Prevention and Health Promotion met several times and involved a network of hundreds of clinicians and researchers in systematic reviews of evidence, many of which were published in the medical literature (3). The Guide to Clinical Preventive Services, published in 1989 and updated in 1996, includes recommendations for screening for high blood cholesterol, hypertension, cancer, diabetes mellitus, depression, the abuse of alcohol and other drugs, and several other conditions in which behavioral interventions have also been developed. Counseling is recommended on exercise, nutrition, preventing tobacco use, and preventing HIV/AIDS and other sexually transmitted diseases. The Guide notes that some of these services may be more effectively given by "non-physicians with special training," such as nurses, dieticians, smoking cessation counselors, and mental health professionals (3, p. xxvii). In practice, there are many structural and payment barriers to including allied health professionals in preventive interventions, but a variety of multidisciplinary team strategies are being developed through partnerships among clinicians at academic health centers, preventive and family medicine residency programs, health departments, mental health professionals, and other practitioners. To support and coordinate the implementation of the Task Force recommendations, ODPHP has developed a national con-

Clinical Practice Guidelines tinuing education initiative called "Put Prevention Into Practice." Clinical guidelines and other materials are available in several formats for providers and patients, including office materials such as wall charts, flow sheets for medical charts, and guides for self-monitoring at home. Workshops and seminars have been held at meetings of the American Public Health Association, the American College of Preventive Medicine, and the American Academy of Family Physicians, and technical assistance is available to ensure uniform implementation of the standards. This ensures that clinical data systems can also be standardized nationally, thus helping to improve the information infrastructure of clinical preventive services and populationbased indicators related to Healthy People 2000 objectives.

Managed Care Organizations Over 60% of the American work force is now enrolled in managed care plans (28), which are based on networks of providers and supported by advanced informationsystems. Managed care organizations build these networks of providers in several ways. The most familiar managed care models are health maintenance organizations (HMOs). In staff-model HMOs, such as Group Health Cooperative of Puget Sound, clinical providers are salaried employees hired directly by the plan. In Kaiser Permanente and other group-model HMOs, the plan negotiates contracts with a group of providers to see patients on a prepaid basis (29-31). Another form of managed care is independent practice associations (IPAs), which allow providers to see a mixture of HMO and fee-for-service patients in their own offices. In another model, preferred provider organizations (PPOs) negotiate reduced rates with selected providers and hospitals; plan members are given incentives, such as lower rates, to use the preferred provider but can still get care outside of the plan. In point-of-service plans, members can choose among alternative delivery systems at the time they seek care (32). Managed care arrangements share the goal of cost-conscious clinical decisionmaking, with an emphasis on primary care and preventive services over specialty services and hospitalization and greater use of non-physician providers. Coordination of care within health plans is central to improving outcomes related to both cost and quality (29,33), so guidelines are needed to integrate the clinical data systems and to standardize practice. The original group practice settings were developed by providers who believed there would be a better quality of care through increasing the flow of information among providers, including shared medical records, clinical consultation, and ongoing peer review (34). In the 1990s, providers may be more likely to see managed care plans as the preferred way to maintain clinical and cost-effectiveness in treatment and preventive services within cost contraints (35). Large HMOs, insurance companies, and drug companies are beginning to analyze medical records and claims data to determine the clinical effectiveness of treatments, providers, and practice settings (36), a trend that is likely to continue. Broadly speaking, the quality of medical care is similar in managed care compared with fee-for-service settings (29,34,37). However, trade-offs between quality and cost are inevitable and problematic at the clinical level (31,33). In feefor-service systems, practitioners have an incentive to provide services whether they are necessary or not. In capitated systems, providers are prepaid a set amount to provide all care for an identified population, which produces incentives to keep

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their plan members healthy through easy access to preventive services, including health education. However, capitation also gives an incentive to provide only the services that are medi= cally necessary, which is why standards of practice and other guidelines are so important in maintaining quality and appropriateness of care and consumer satisfaction. Medical/surgical and behavioral health benefits are usually negotiated, managed, and provided by separate systems. Managed mental health care, or behavioral health, developed in the late 1980s as a way of controlling rapid increases in the costs for mental health and substance abuse treatment, which represented 15 to 25% of total health care expenditures (38). Having separate systems for behavioral and physical health also can safeguard confidentiality for such sensitive services as psychotherapy and treatment for chemical dependency. In managed mental health plans, mental health professionals agree to provide treatment and counseling for mental health problems and chemical dependency for preset fees or under capitation. Depending on the local provider market and patterns of practice, these specialists include a mixture of psychiatrists, social workers, psychologists, counselors, and other allied health personnel (32,38). The separation of medical and behavioral health benefits is desirable from the standpoint of employers who want to control costs without reducing benefits. "Carving out" these specialty services usually means a higher level of benefits can be offered because the employer shares the financial risk with the network of participating specialists. Well-designed, integrated behavioral health systems may be more effective at controlling costs and quality than utilization review (32). However, networks are naturally viewed with suspicion by mental health practitioners and other specialty providers who maintain solo, fee-for-service practices. Membership in HMOs is growing at a rate of 11% a year, including an increasing proportion of Medicaid recipients. HMOs can be extremely profitable: the combined assets of nine of the largest approach $9.5 billion, and some observers suggest that the profits should be returned to patient care or that premiums should be lowered. Non-profit HMOs such as Kaiser Permanente and many Blue Cross plans spend more on medical care than for-profit HMOs, but all HMOs have a goal of providing effective care efficiently, and competition among them is changing the culture of primary care and specialty services in profound ways (39,40). IMPLEMENTATION OF CLINICAL GUIDELINES Guidelines are not self-implementing. Regardless of practice setting, the act of distributing guidelines carries no guarantees that providers will even read them, let alone change their patterns of behavior. Adherence to guidelines can be poor even when providers say they are fully aware of them (41). Greco and Eisenberg (42) reviewed research on changing provider behaviors and found six methods had been tried with physicians: education, feedback, participation in efforts to develop guidelines for change, administrative rules, financial incentives, and financial penalties. While each of these strategies was found to have some independent effects, interventions that involved more than one component were more likely to succeed. The involvement of "opinion leaders" at critical points in development, distribution, and implementation also has been recommended (8,24,42).

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Barriers to Implementation of Guidelines Provider Issues: Clinical autonomy is a strong force in medicine and in allied health professions (35,42-44). Many clinicians believe that their personal judgment based on knowledge of the patient should be the basis of all decisions. Clinicians may be philosophically opposed to what they see as researchers' or administrators' efforts to reduce individuals to numbers, believe that clinical situations are unique and not amenable to standardization, or view guidelines as "cookbook medicine" (16). They may resist computerized record systems because they are expensive, burdensome, difficult to maintain, or hard to learn. Clinicians know that there are often many appropriate treatment strategies, depending on the patient's preferences, health status, and many other determinants. Among non-clinical determinants, insurance status undeniably is primary in shaping individual treatment plans (31), and payment is more often linked to the profession of the person who provides it than to the nature of the procedure or service itself (45). For behavioral medicine interventions, there is no evidence linking more effective practice patterns with certain provider types (e.g. psychology, psychiatry, internal medicine, nursing, and allied health). In theory, behavioral interventions should be comparable across provider types. In 1991, the Physician Payment Review Commission considered the possibility of recommending Medicare formulas for reimbursement that would be comparable for psychiatrists and clinical psychologists (46). The proposal was dropped after it was opposed by the American Psychiatric Association and the American Medical Association. In fee-for-service settings in mental health and chemical dependency, payment differentials are still a contentious issue. In behavioral health organizations and networks, non-physician providers such as psychologists and social workers are often preferred because they cost less than psychiatrists. Research Issues: Experts disagree on what constitutes quality of evidence on clinical effectiveness. Luft (37) has observed that it is not surprising to find contradictory results when researchers disagree about basic technical issues such as design, instrumentation, documentation, and appropriate units of observation and analysis. He was writing about cost containment, but every field of research has its own technical disagreements and conceptual differences among subgroups, often crossing disciplines and professions. The development of guidelines requires agreement on what evidence will be considered. In the social and behavioral sciences and mental health, specialization and competition among psychiatry, psychology, nursing, social work, and counseling are being described as "Balkanization," a reference to Eastern European ethnic violence (47). In both examples, the more similar groups appear to outsiders, the more the internal distinctions are defended. Turf battles in behavioral and psychosocial research and practice have remained incomprehensible to policymakers and the public, and they are major obstacles to the coordination and advancement of policy-relevant behavioral research. That being said, good researchers in all fields usually raise as many questions as they answer in published studies. Given an opportunity to make suggestions to policymakers, most researchers recommend increased funding and further research to add to the knowledge base. The tendency to always call for additional research does not take advantage of opportunities to

Edmunds provide clear guidance to policymakers on what is currently known about the appropriateness and effectiveness of behavioral interventions. Nor is it responsive to the need for policyrelevant applications for research findings or assisting in evidence-based policy development.

OPPORTUNITIES FOR I N V O L V E M E N T Guideline Development and Implementation Behavioral medicine practitioners and researchers have been underinvolved in the development and implementation of guidelines in the past, but their training and experience can make a unique contribution in these areas. By definition, behavioral interventions use observable, objective measures (e.g. frequency, duration, intensity), which should be directly transferable to the development of clinical indicators and performance measures. Clinicians and researchers should become familiar with existing guidelines by AHCPR and professional organizations in their areas of interest, find out what guidelines are being used in their own institutions, and ensure that the behavioral components of guidelines are implemented. Professional organizations can nominate researchers and clinicians with behavioral expertise for participation in future AHCPR panels and other multidisciplinary efforts and can publicize the participation in guideline development when they are released. Organizations can sponsor the development of consensus statements among their members and seek joint sponsorship from other organizations, including multidisciplinary and community-based coalitions with similar interests. National public health guidelines have already been released for physical activity (11). Future priorities for consensus statements and more formal development of guidelines would be in policyrelevant areas with a strong behavioral research base, such as smoking cessation, alcohol and drug abuse, HIV/AIDS, violence, and other relevant Healthy People 2000 priority areas. Multidiseiplinary Research Practice guidelines are based on a synthesis of relevant research. For the multidisciplinary behavioral medicine research community to develop guidelines, it would need to find common ground from effectiveness research conducted across health psychology, medicine, nursing, psychiatry, epidemiology, behavioral sciences, women's health, environmental health, and other fields. From a behavioral medicine perspective, the development of practice guidelines could help to standardize measurement and methodology and to strengthen the areas of agreement among researchers in discussions with policymakers. Randomized controlled trials may be a gold standard, but they are also very expensive and time-consuming, and random assignment often raises ethical considerations, especially in community-based research. Longitudinal observational studies allow large-scale comparisons about the effectiveness of practices by various providers, in different settings, for different subgroups of patients, and they can be extremely useful if they are carefully designed and have good outcome and case-mix measures (50). Multicomponent interventions are more likely to be cost-effective, and they can be evaluated to determine the relative effectiveness of different components among subgroups (52). At the NIH, research on health and behavior is supported by several of the Institutes, with a combined level of $835.2 million, or 8% of the total NIH budget of $10 billion (53). The NIH Health and Behavior Coordinating Committee and the new

Clinical Practice Guidelines Office of Behavioral and Social Sciences Research will play key roles in coordinating behavioral research across the NIH. In public health, there is growing interest in working with researchers on behavioral risk reduction in multicomponent, community-based prevention programs for tobacco control and prevention of HIV/AIDS, teen pregnancy, and other complex issues. Media coverage of scientific studies plays a visible and important role in communicating research findings to the public, policymakers, and other researchers. One study found that articles that were covered by The New York Times were more likely to be cited in the scientific literature (54), and they are more likely to reach policymakers and the public. Researchers who are attuned to the potential clinical and policy applications of their findings will be in increasing demand for media campaigns with public health messages, for community-based coalitions on behavioral risk reduction, and for the design of comprehensive, multicomponent programs.

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search and practice, help to promote best practices, and increase consumer satisfaction. From the perspective of behavioral medicine, guidelines offer an opportunity to increase awareness about the effectiveness of behavioral interventions as part of multicomponent treatment and prevention strategies. Behavioral risk factors such as physical inactivity, poor nutrition, substance abuse, and unsafe sex are among the primary determinants of health, yet behavioral researchers and clinicians have been underinvolved in the development of guidelines for use by primary care providers and population-based prevention programs. This needs to change. Health behaviors are the key to health promotion and disease prevention, and knowledge about behavior change is key in designing effective interventions at all levels, including patients, providers, organizations, and communities. By communicating a clear message about the effectiveness of behavior change strategies, behavioral medicine can increase its influence on policy as well as practice.

Public Health The Office of Disease Prevention and Health Promotion has a Congressional mandate to coordinate and monitor national prevention policy and program development in disease prevention, health promotion, preventive health services, and health information and education (48). With leadership from the former Deputy Assistant Secretary for Health, J. Michael McGinnis, ODPHP developed Healthy People 2000, a national health policy framework for individual, collective, and environmental change. Healthy People 2000 has three national goals: (a) increasing the healthy life span; (b) reducing and eliminating disparities in health status; and (c) ensuring access to preventive services for all Americans (49). Healthy People 2000 contains 200 national objectives in 22 priority areas addressing health promotion, health protection, preventive services, and data systems. Behavioral factors are key to several of the priority areas, including physical activity and fitness, nutrition, tobacco, alcohol and other drugs, family planning, mental health, violent and abusive behavior, heart disease and stroke, cancer, diabetes and chronic conditions, HIV infection, and sexually transmitted diseases. While the objectives have been adapted by state and local public health agencies, increasing collaboration with behavioral experts could be extremely productive. The joint recommendations of the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine are a recent example of a broad-based collaborative effort to develop public health guidelines at the national level (11). National policymakers can endorse such recommendations, but the leadership in implementation usually comes from professional organizations, community leaders, and other individuals. CONCLUSIONS AND IMPLICATIONS From a policy perspective, clinical practice guidelines are an objective synthesis of research findings and clinical judg-, ments and a necessary tool in decision-making about the rational allocation of public resources. Guidelines can coordinate the delivery of care, improve the quality of care, and standardize the collection of clinical data for use in outcomes research. The development of guidelines can help bring multidisciplinary agreement and consensus, strengthen the linkages between re-

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