Clinical practice guidelines (CPGs) relate to clinical matters, generally dealing with clinical conditions or symptoms, and are usually meant for use by health-care providers and other health-care actors such as health services managers, payers, patients, and their caregivers. Clinical guidelines are standardised recommendations for health-care practitioners on how to diagnose and treat medical conditions systematically to ensure that patients receive optimal health care. These clinical guidelines usually summarise the most updated medical knowledge and weigh the benefits and harms of diagnostic and treatment procedures to provide statements that include recommendations based on recent high-quality medical evidence or health technology assessment with a view to optimising patient care. Therefore, they should be reviewed and updated regularly. Clinical guidelines are not legally obligatory. They assist health-care practitioners and patients in deciding on appropriate health care for particular clinical circumstances, which means that health-care providers do not have to follow the recommendations if they believe they are not suitable for some patients based on their clinical judgments, but deviations from guidelines must be justified (1-3).
Clinical guidelines are meant to enhance the effectiveness and quality of care, decrease variations in clinical practice, and reduce the costs from unnecessary medical procedures, preventable mistakes, and adverse events. Quality improvement initiatives are associated with CPGs, as evidence-informed recommendations constitute the basis for identifying core outcomes and measurable standards of care (2). Both health-care regulators and payers can use measurable standards of care. Health-care regulators can use measurable standards to assess the performance of health-care providers and to monitor patient safety, while health-care payers who adopt the strategy of performance-based pay or value-based health-care payment can use measurable standards to reward or penalise health-care providers. Furthermore, clinical guidelines can be used in local contexts as a reference for standardised medical procedures by health-care payers to estimate the local costs of health-care services.
In recent decades, several non-profit organisations have invested in the CPG industry worldwide, including the World Health Organization (WHO), the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), and the Australian National Health and Medical Research Council (NHMRC). The investment usually includes CPG development, reporting, adoption, contextualisation or adaptation, evaluation, and implementation (2). The continuing innovations in health-care technologies and the growing amount of medical evidence used in this field can be overwhelming and require consistent investment of more resources in the CPG industry.
However, investing in the CPG industry may have unintended consequences. First, they may fail to change practice. Dissemination strategies can be distinguished as being either active or passive. The active or dynamic dissemination approach, which is preferred among health-care practitioners, involves procedures such as proactive education of health-care practitioners, electronic reminder systems, and audit and feedback, while the passive dissemination approach is mainly based on publishing or mailing updated information (4-8). Taking diabetes CPGs as an example, the evidence shows that the level of diabetes CPG awareness among health-care providers, which is considered an indicator of greater adherence to the guidelines, ranges between 75% and 89% in Turkey, the United States, and China. In comparison, it is around 51% in Saudi Arabia (6). The low level of CPG awareness among health-care providers may lead to lowering the value that is supposed to be returned from investing in the CPG industry.
Second, CPGs may face professional resistance. Some health-care practitioners do not follow CPGs, as they argue that each patient has different needs, particularly in terms of medicine. These reasons and unsustainable resources for investment may lead health-care policymakers to be hesitant to commit to such investment. However, this can be addressed if health system policymakers use a more proactive strategy for dissemination and link the quality initiatives with the payment systems to health-care providers, which would increase the level of CPG awareness among health-care providers intuitively.
Third, insufficient investment in the CPG industry may also lead to unintended consequences related to using low-quality clinical guidelines not updated according to the most recent and high-quality evidence-based medicine or health technology assessment, which may lead to patients being prevented from receiving the most effective treatments available in the market or sometimes being over treated, which will in turn affect patients’ health outcomes and the cost of care (2, 9-11).
Taking their promise and unintended consequences together, there are contradictory opinions among health-care policymakers about the importance of sustained investment in the CPG industry to providing unified national CPGs that can be used locally as a reference by health system actors, including health-care providers, regulators, and payers, and consequently whether such investment would have a significant impact on quality of care measures such as patients’ health outcomes and the cost of care. In view of these tensions, this review has been conducted to facilitate evidence-informed policymaking and to help health-care policymakers in Saudi Arabia to decide whether or not sustainable investment in the CPG industry is socially and economically viable. This is done through answering the following question: Do CPGs improve clinical practice, and do they help save money?