Skip to main content Accessibility help
Hostname: page-component-7ccbd9845f-dzwm5 Total loading time: 0.43 Render date: 2023-01-30T22:31:23.491Z Has data issue: true Feature Flags: { "useRatesEcommerce": false } hasContentIssue true

Clinical practice guidelines and organizational adaptation: A framework for analyzing economic effects

Published online by Cambridge University Press:  27 February 2006

John E. Schneider
University of Iowa and Iowa City VA Center for Research in the Implementation of Innovative Strategies in Practice
N. Andrew Peterson
University of Iowa
Thomas E. Vaughn
University of Iowa and Iowa City VA Center for Research in the Implementation of Innovative Strategies in Practice
Eric N. Mooss
Alegent Health
Bradley N. Doebbeling
Indiana University and Roudebush VA Center on Implementing Evidence-Based Practice


Objectives: The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs.

Methods: An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors.

Results: The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management.

Conclusions: Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.

© 2006 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Akerlof GA, Kranton RE. 2005 Identity and the economics of organizations. J Economic Perspect. 19: 932.Google Scholar
Anand G. 2003; The big secret in health care: Rationing is here. The Wall Street Journal. A1A6.Google Scholar
Audet A, Greenfield S, Field M. 1990 Medical practice guidelines: Current activities and future directions. Ann Intern Med. 113: 709714.Google Scholar
Berwick DM. 2000 A User's Manual for the IOM's ‘Quality Chasm’ Report. Health Affairs. 21: 8090.Google Scholar
Borkowski N, Allen W. 2002 Using organizational behavior theories to manage clinical practice guideline implementation. J Am Acad Business. 1: 365370.Google Scholar
Brady L. 1994 Purchasers pursue process to standardize orthopedic implants. Health Industry Today. 57: 13.Google Scholar
Brennan TA. 1995: Methods for setting priorities for guideline development: Medical malpractice. In: IOM, ed. Setting priorities for clinical practice guidelines. Washington, DC: National Academies Press; 99110.
Browman GP. 2000 Improving clinical practice guidelines for the 21st century: Attitudinal barriers and not technology are the main challenges. Int J Technol Assess Health Care. 16: 959968.Google Scholar
Buckley CJ, Patterson DE, Manning LG, Lee SD. 2001 Quality vascular surgical care: The importance of innovation and change in an era of dwindling reimbursement. South Med J. 94: 411416.Google Scholar
Cabana MD, Rand CS, Powe NR, et al. 1999 Why don't physicians follow clinical practice guidelines? JAMA. 282: 14581465.Google Scholar
Carpenter CE, Nash DB, Johnson NE. 1993 Evaluating the cost containment potential of clinical guidelines. QRB Qual Rev Bull. 19: 119123.Google Scholar
Casalino LP, Gillies RR, Shortell SM, et al. 2003 External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 289: 434441.Google Scholar
Coddington DC, Moore KD. 2002 Leading IDSs heed the call to invest in IT. Healthc Financ Manage. 56: 3640.Google Scholar
Costantini O, Huck K, Carlson MD, et al. 2001 Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure. Arch Intern Med. 161: 177182.Google Scholar
Cromwell J, Bartosch WJ, Fiore MC, et al. 1997 Cost effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA. 278: 17591766.Google Scholar
Cruz-Correa M, Gross CP, Canto MI, et al. 2001 The impact of practice guidelines in the management of Barrett esophagus. Arch Intern Med. 161: 25882595.Google Scholar
Davenport TH. 1993. Process innovation: Reengineering work through information technology. Boston, MA: Harvard Business School Press;
Devaraj S, Kohli R. 2000 Information technology payoff in the health care industry: A longitudinal study. J Manage Inform Syst. 16: 4167.Google Scholar
Devlin JW, Holbrook AM, Fuller HD. 1997 The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost. Ann Pharmacother. 31: 689695.Google Scholar
Finkler SA, Ward DM. 2003 The case for the use of evidence-based management research for the control of hospital costs. Health Care Manage Rev. 28: 348365.Google Scholar
Flanagan JR, Doebbeling BN, Dawson J, Beekmann S. 1999; Randomized study of online vaccine reminders in adult primary care. Proc AMIA Symp. 755759.Google Scholar
Forgionne GA. 1996 A management support system to facilitate TQM for hospitals. Information Syst Eng. 2: 119138.Google Scholar
Gandjour A, Lauterbach KW. 2001 A method for assessing the cost effectiveness and the break-even point of clinical practice guidelines. Int J Technol Assess Health Care. 14: 503516.Google Scholar
Granata AV, Hillman AL. 1998 Competing practice guidelines: Using cost-effectiveness analysis to make optimal decisions. Ann Intern Med. 128: 5663.Google Scholar
Greene RA, Beckman H, Chamberlain J, et al. 2004 Increasing adherence to a community-based guideline for acute sinusitis through education, physician profiling, and financial incentives. Am J Manage Care. 10: 670678.Google Scholar
Greve HR. 2003. Organizational learning from performance feedback: A behavioral perspective on innovation and change. Cambridge: Cambridge University Press;
Grimshaw JM, Russell IT. 1993 Effect of clinical guidelines on medical practice: A systematic review of rigorous evaluations. Lancet. 342: 13171322.Google Scholar
Grimshaw JM, Hutchinson A. 1995 Clinical practice guidelines–Do they enhance value for money in health care? Br Med Bull. 51: 927940.Google Scholar
Grol R. 2000 Between evidence-based practice and total quality management: The implementation of cost-effective care. Int J Qual Health Care. 12: 297304.Google Scholar
Gunasekaran A, Nath B. 1997 The role of information technology in business process reengineering. In J Product Economics. 50: 91104.Google Scholar
Hackman JR, Wageman R. 2000: Total quality management: Empirical, conceptual, and practical issues. In: Scott WR, Cole RE, eds. The quality movement & organization theory. London: Sage Publications; 2348.
Hall L, Eccles M. 2000 Case study of an inter-professional and inter-organisational programme to adapt, implement and evaluate clinical guidelines in secondary care. Clin Perform Qual Health Care. 5: 7282.Google Scholar
Harvey G, Loftus-Hills A, Rycroft-Malone J, et al. 2002 Getting evidence into practice: The role and function of facilitation. J Adv Nurs. 37: 577588.Google Scholar
Haycox A, Bagust A, Walley T. 1999 Clinical guidelines-The hidden costs. Br Med J. 318: 391393.Google Scholar
Hesson D. 2004 Indiana system finds standardizing pays off. Hosp Materials Manage. 29: 1011.Google Scholar
Hu TW, Stotts NA, Fogarty TE, Bergstrom N. 1993 Cost analysis for guideline implementation in prevention and early treatment of pressure ulcers. Decubitus. 6: 4246.Google Scholar
1990. Institute of Medicine. Clinical practice guidelines: Directions for a new program. Washington, DC: National Academy Press;
1995. Institute of Medicine. Setting priorities for clinical practice guidelines. Washington, DC: National Academy Press;
2001. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press;
James AA, Shorr RI, Flach SD, et al. Are clinicians aware of computer reminders to implement practice guidelines? A national survey. Society of General Internal Medicine Southern Regional Meeting. 2003. New Orleans, LA.
Kenkel DS. 2000: Prevention. In: Culyer AJ, Newhouse JP, eds. Handbook of health economics. New York: Elsevier Science; 16751720.
Kibbe DC. Information management and technology for CQI. In: McLaughlin CG, Kaluzny AD, eds. 1999. Continuous quality improvement in health care: Theory, implementation, and applications. Gaithersburg, MD: Aspen Publishers, Inc;
Kitson A, Harvey G, McCormack B. 1998 Enabling the implementation of evidence based practice: A conceptual framework. Qual Health Care. 1998: 149158.Google Scholar
Kizer KW. 2000 Promoting innovative nursing practice during radical health system change. Nurs Clin North Am. 35: 429441.Google Scholar
Kovener AR, Elton JJ, Billings J, Short JH. 2000 Evidence-based management. Front Health Serv Manage. 16: 3.Google Scholar
Laliberty R. 1988. Decentralizing health care management: A manual for department heads and supervisors. Owings Mills, MD: National Health Publishing;
Larson E. 2003 Status of practice guidelines in the United States: CDC guidelines as an example. Prev Med. 36: 519524.Google Scholar
Leatherman S, Berwick DM, Iles D, et al. 2003 The business case for quality: Case studies and an analysis. Health Affairs. 22: 1730.Google Scholar
Lewis AG. 2001. Streamlining health care operations: How lean logistics can transform health care organizations. San Francisco, CA: Jossey-Bass;
Lohr KN. 1994 Guidelines for clinical practice: Applications for primary care. Int J Qual Health Care. 6: 1725.Google Scholar
Lu-Yao G, Albertsen PC, Stanford JL, et al. 2002 Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut. Br Med J. 325: 740745.Google Scholar
Macintyre CR, Plant AJ, Hendrie D. 2000 The cost-effectiveness of evidence-based guidelines and practice for screening and prevention of tuberculosis. Health Econ. 9: 411421.Google Scholar
March JG. 1996: Exploration and exploitation in organizational learning. In: Cohen MD, Sproull LS, eds. Organizational learning. Thousand Oaks, CA: Sage; 101123.
Mille D, Roy T, Carrere M, et al. 2000 Economic impact of harmonizing medical practices: Compliance with clinical practice guidelines in the follow-up of breast cancer in a french comprehensive cancer center. J Clin Oncol. 18: 17181724.Google Scholar
Miller AB, To T, Baines CJ, Wall C. 2002 The Canadian National Breast Screening Study-1: Breast cancer mortality after 11 to 16 years of follow-up. Ann Intern Med. 137: 305312.Google Scholar
Mostafa G, Sing RF, Matthews BD, et al. 2002 The economic benefit of practice guidelines for stress ulcer prophylaxis. Am Surg. 68: 146150.Google Scholar
Nelson RR, Winter SG. 1982. An evolutionary theory of economic change. Cambridge, MA: Belknap Press;
Nestor A, Calhoun AC, Dickson M, Kalik CA. 1998 Cross-sectional analysis of the relationship between national guideline recommended asthma drug therapy and emergency/hospital use within a managed care population. Ann Allergy Asthma Immunol. 81: 327330.Google Scholar
Nooteboom B. 2000. Learning and innovation in organizations and economies. New York: Oxford University Press;
O'Brien JA, Jacobs LM Jr, Pierce D. 2000 Clinical practice guidelines and the cost of care. Int J Technol Assess Health Care. 16: 10771091.Google Scholar
O'Connor PJ, Solberg LI, Christianson J, et al. 1996 Mechanism of action and impact of a cystitis clinical practice guideline on outcomes and costs of care in an HMO. Jt Comm J Qual Improv. 22: 673682.Google Scholar
Phillips KA, Kerlikowske K, Baker C, et al. 1998 Factors associated with women's adherence to mammography screening guidelines. Health Serv Res. 33: 2953.Google Scholar
Piecoro LT, Potoski M, Talbert JC, Doherty DE. 2001 Asthma prevalence, cost, and adherence with expert guidelines on the utilization of health care services and costs in a state Medicaid population. Health Serv Res. 36: 357371.Google Scholar
Pitimana-aree S, Forrest D, Brown G, et al. 1998 Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care. Intensive Care Med. 24: 217223.Google Scholar
Rafferty AM, Ball J, Aiken LH. 2001 Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Qual Health Care. 10: ii32ii37.Google Scholar
Rolnick SJ, O'Connor PJ. 1997; Assessing the impact of clinical guidelines: Research lessons learned. J Ambul Care Manage. 20: 4755.Google Scholar
Shekelle PG, Kravitz RL, Beart J, et al. 2000 Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making. Health Serv Res. 34: 14291448.Google Scholar
Silagy CA, Weller DP, Lapsley H et al. 2002 The Effectiveness of Local Adaptation of Nationally Produced Clinical Practice Guidelines. Fam Pract. 19: 223230.Google Scholar
Skinner W. 1974 The focused factory. Harvard Business Rev. 52: 113120.Google Scholar
Smith TJ, Hillner BE. 2001 Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways. J Clin Oncol. 19: 28862897.Google Scholar
Suarez-Almazor ME, Belseck E, Russell AS, Mackel JV. 1997 Use of lumbar radiography for the early diagnosis of low back pain. JAMA. 277: 17821786.Google Scholar
Teece DJ, Pisano G. 1994 The dynamic capabilities of firms: An introduction. Indust Corporate Change. 3: 537556.Google Scholar
Teece DJ, Rumelt R, Dosi G, Winter S. 1994 Understanding corporate coherence: theory and evidence. J Econ Behav Org. 23: 130.Google Scholar
Tengs TO, Adams ME, Pliskin JS, et al. 1995 Five hundred life-saving interventions and their cost-effectiveness. Risk Anal. 15: 369391.Google Scholar
Varrone C. Enduring cost advantage. II. Richest sources of savings: Lessons from America's lowest-cost hospitals. Washington, DC: The Governance Committee, The Advisory Board Company.
Vaughn TE, McCoy KD, BootsMiller BJ, et al. 2002 Organizational predictors of adherence to ambulatory care screening guidelines. Med Care. 40: 11721185.Google Scholar
Walshe K, Rundall T. 2001 Evidence-based management: From theory to practice in health care. Milbank Q. 79: 429457.Google Scholar
Weingarten SR, Riedinger MS, Conner L, et al. 1994 Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. Ann Intern Med. 120: 257263.Google Scholar
Winter SG. Organizing for continuous improvement: Evolutionary theory meets the quality revolution. In: Cohen MD, Sproul LS, eds. Organizational learning. Thousand Oaks, CA: Sage; 1996: 460483.
Wruck KH, Jensen MC. 1994 Science, specific knowledge, and total quality management. J Account Econ. 18: 247287.Google Scholar
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Clinical practice guidelines and organizational adaptation: A framework for analyzing economic effects
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Clinical practice guidelines and organizational adaptation: A framework for analyzing economic effects
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Clinical practice guidelines and organizational adaptation: A framework for analyzing economic effects
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *