The development of practice policies or clinical guidelines has recently met with great popularity in many countries.(1)(2)(3)(4) National consensus development, modeled after the original National Institutes of Health procedure, can be seen in Canada, Scandinavian countries, France, the United Kingdom, the Netherlands, and elsewhere. A more recent initiative is the clinical guideline development by the Agency for Health Care Policy and Research (AHCPR) in the United States.(5) Guidelines are also developed on a large scale by professional bodies and by regional or local groups of care providers and other organizations.(2) Guideline setting is now considered by most policymakers and professional organizations of care providers to be a priority, and essential for the improvement of the quality and efficiency in health care.

A crucial question in this development is: how effective are all these different approaches for setting guidelines? This paper outlines a method for national guideline development for family practice in the Netherlands and provides a comparison of this method with that of the AHCPR in the United States.(6)(7)(8)(9) In the Netherlands, national guidelines for family practice care have been developed and disseminated in a rigorous, structured manner since 1987.(10)(11)(12) More than 45 of these guidelines covering a wide range of topics have been disseminated among more than 80% of all Dutch family physicians. Using a systematic updating program, which was started in 1991, eight to ten new topics are addressed each year. The guidelines are developed by the Dutch College of General Practitioners (NHG), the scientific organization of family physicians, while the National Association of Family Physicians (LHV, the “union”) is responsible for their implementation. A large majority of the almost 7000 practicing family physicians are members of these professional bodies.

This guideline initiative has been quite successful because it is initiated and “owned” by the family physicians themselves. It is also linked to the specific role of the family physician in the Dutch health care system: being the gatekeeper for specialist care, providing long-term, continuous care to patients, and treating patients for minor as well as chronic problems. In addition, guideline development is being adapted to the morbidity in primary care. Watchful waiting and the prevention of unnecessary or potentially harmful care, therefore, are important basic values for the guidelines. The emphasis in the model for Dutch guideline setting differs considerably from that of the AHCPR (Table), which has focused on expensive procedures, such as cataract surgery.

Table. Differences in Aims and Emphasis Between Guideline-Setting

Procedures of the Agency for Health Care Policy and Research (AHCPR) and the Dutch College of General Practitioners

AHCRP                                Dutch College
* Governmental initiative        * Initiative of professional
organization of family
physicians
* Mainly experts developing      * Experts and practitioners
guidelines                      developing guidelines
* Multidisciplinary, including   * Only family physicians
consumers
* Strong emphasis on evidence-   * Emphasis on mixture of
based, scientifically
justified                       scientific evidence and
guidelines                      feasibility in practice
* Development and
implementation                 * Implementation is part of
are separate processes          developmental process
* Patient/consumer preferences
on                             * Patient preferences not
outcomes taken into account     included
* Small range of topics           * Broad range of topics
* Development carried out by     * Development by and owned
independent scientific
institutions                    by family physicians
(contractors)
* Central aim: elimination of    * Central aim: supporting family
inappropriate, unnecessary,
and                             physicians in daily work and
inefficient care                strengthening family medicine
as an independent specialism

Guideline-Setting Procedures of the Dutch College of General

Practitioners

The 45 guidelines as developed by the Dutch College cover a wide range of problems and conditions seen in family practice, such as type II diabetes, sprained ankle, otitis media, dementia, and sleeping disorders. A guideline incorporates statements on adequate care, sometimes in the form of an algorithm, and supporting background materials. It is structured according to the steps involved in patient contacts (history, examinations, tests, evaluation, patient education, treatment, follow-up, referral), preceded by a clarification of terms and concepts. The aim of guideline development is to provide family physicians with a point of reference for their daily work and to provide a basis for continuing medical education and postgraduate training for family physicians.