THE PARADOX OF GUIDELINE IMPLEMENTATION - HOW AHCPRS DEPRESSION GUIDELINE WAS ADAPTED AT KAISER-PERMANENTE NORTHWEST REGION

Background: To ensure implementation, the Agency for Health Care Polic y and Research's (AHCPR) Guideline for the Treatment of Depression in Primary Care was recently translated into a local document by a large health maintenance organization. (HMO). The guideline revision process was studied on the basis of interviews with members of the guideline revision committee and others, observation of meetings, and documents and correspondence. Why the guideline was changed: The HMO changed the AHCPR guideline for reasons of conveinence, credibility, audience, pu rpose, and context. For example, in their roles as representative cons umers, committee members perceived that the AHCPR guideline, although addressed to primary care clinicians, was actually written from a psyc hiatric perspective and based on a psychiatric literature not relevant to primary care. Comparison of the guidelines: Although the guideline s differ dramatically in length and format, coverage, emphasis, and or ganizing principle, substantive conflict between the two guidelines' r ecommendations is minimal. For example, the emphasis on medication is greater in the adaptation, which adds considerable original material o f a practical nature on drugs and drug use. In addition, the original guideline has a ''research literature orientation.'' In contrast, the adaptation is described as ''clinical decision oriented,'' identifying the key actions and decisions that a practicing clinician must make t o treat depression. Discussion and implications: Translation of scienc e-oriented national guidelines into user-oriented documents tailored t o local audiences and settings can add great value to the guideline de velopment process without sacrificing science-derived integrity-and is probably essential to successful implementation.