As discussed earlier, there is ample research showing that all stakeholders benefit from healthcare quality improvement programs using evidence-based practice guidelines. Many of the guidelines existing today, however, have serious limitations and do not always deliver the predicted improvements in care.[1,2,3,4] Furthermore, while QI programs seek to implement high-quality care based on the available evidence, there is a lack of: (a) rigorous research evaluating the use of practice guidelines and their outcomes, (b) valid methods for selecting specific interventions for a particular patient in particular circumstances, and (c) effective software tools assisting providers and patients in implementing recommended interventions.[5]

Fortunately, other factors drive the adoption of care quality improvement.[6,7,8] Following discusses these and other problems with practice guidelines and QI programs, and offers solutions.

Problem: Many of Today’s Guidelines are Immature or Invalid


A particular guideline may not be appropriate for all patients with a particular diagnosis.

For example, procedures recommended for someone with heart disease may be contraindicated for a person with both heart disease and lung disease. In addition, a person’s age, gender, genetics, environment, concomitant treatments, and other factors may have to be considered before determine if a particular guideline is appropriate. Furthermore, while certain guidelines may work well for certain patients short-term, they may cause long-term problems.

Because very few guidelines are likely to be appropriate for all patients with the same problem and diagnosis, it means they should be tailored to the particular needs, conditions, and preferences of each patient. That is, they must be fine-tuned to account for the vast number of factors influencing outcomes and to guide stakeholders in selecting the right guidelines for each patient and each episode of care. This requires accumulation and analysis of massive amounts of clinical data from a multitude of patient populations, as well as intensive ongoing controlled clinical trials and real-world research across multiple clinical and organizational settings. Unfortunately, neither the data nor the research is adequate today; once published and circulated, there are relatively few well designed evaluations of their cost-effectiveness.[9,10,11]

According to a 2002 survey of healthcare experts and review of the research literature, almost half of the Agency for Healthcare Research and Quality’s (AHRQ’s) 17 practice guidelines were obsolete and should be withdrawn, and other require additional information to be useful. Three guidelines were judged sufficiently valid to remain in circulation.[12]

Solution: Develop and Validate Evolving Guidelines


Providers and researchers must collaborate to develop and validate a wealth of practice guidelines that can be used with confidence for a wide range of patients and healthcare problems. Consensus conferences, use of collaboration technologies, funding controlled clinical trials and real-world research, and widespread sharing of lessons learned and anecdotal information would all lead to development of better guidelines that continue to evolve over time.


Problem: Current Diagnostic Codes are Inadequate


Another reason for the inadequacy of guideline research is the problem with diagnostic codes. That is, diagnoses from the ICD (all versions) have several serious limitations, including the fact that they are not detailed enough to describe the nuances of all diseases and conditions.[13,14,15] And the DSM (all versions), which is used by mental healthcare providers, suffers the same problems, with the addition that it is not designed as a vehicle to tie diagnosis to treatment decisions.[16]

Since guideline selection is based on a patient’s diagnosis, we need a diagnostic system with scalpel-like precision, which accounts for all the important variables necessary to match patient to guideline with great accuracy.

Solution: Develop More Precise Diagnostic Codes


The ability to match guidelines to patients would be enhanced with efforts to improve the precision of current data diagnostic codes used by all healthcare disciplines. Diagnoses should be broken down into as many subcategories as is necessary to enable reliable selection of guidelines for each patient’s particular problems, characteristics, and needs.

One way to increase diagnostic precision is to develop an evolving index of all:

  • Physical, cognitive, perceptual, emotional, and behavioral symptoms a person may have
  • Patient characteristics, such as gender, age, race, etc.
  • Genetic factors likely to affect a patient’s response to a certain drug, etc.
  • Probable causes of the symptoms, including environmental (e.g., germs, pollution, etc.) psychological (mental and emotional), genetic defect, experiential, dietary, trauma (from accidents, abuse, war, etc.), smoking and alcohol consumption, improper healthcare treatments, etc.
  • Treatments (procedures, medications, techniques, etc.) that resolved or managed the symptoms.

This information should be accumulated at a greater level of depth than exists today. For example, instead of collecting data from billing codes indicating “malignant tumor,” the data should include the tumor’s size, type, location, etc. And instead of just saying “depression,” the data should include coexisting medical illnesses, etc. that may be related to the depressions, as well as types of cognitions and behaviors associated with it.

With this degree of specificity, instead of just associating a general practice guideline a general diagnosis, a precise diagnosis would be defined as a particular set of symptoms and related factors, with a particular set of causes, for a person with a particular set of characteristics. The guideline of choice would then be the most cost-effective treatments found to work best with this precise diagnosis.

Analyzing these data would yield findings serving as evidence of important correlations, such as whether more cancer patients with a certain genetic marker responded better to drug A versus drug B. That kind of information can help a doctor determine the best chemotherapy plan for a patient. It would also lead to tailored treatments that take into account everything known about a patient and similar patients and the most effective ways to treat those people.[17]

This can be done through the collaboration of detailed patient data and ongoing research. Over time, diagnostic categories would become ever more precise and usable in clinical decision making and guideline selection.

One promising approach is "ABC coding," which supports a more precise and comprehensive documentation of patient encounters and a common language for comparing approaches to care.[17a] Another is to use a computerized diagnostic coding system that implement a "diagnostic entity code database" and "classification rules" to provide precise and useful diagnostic information.[17b]


Problem: Lack of Adequate Continuity of Care


Continuity of care is the coherent delivery of care across time and place. Care continuity often breaks down, however, when patients with multiple medical problems are transferred between different healthcare facilities and clinicians. For example, breaks in continuity of care occur during patient transfer between providers and between settings, which can occur at patient admission, during nursing shift change and inter-facility transfer while hospitalized, or at discharge, especially at nighttime and on weekends.

Solution: Continuity of Care Coordination


One solution is to use clinical pathways [18] and care coordination protocols [19] to define the particular care patients should receive, when they should receive it, and how the all the clinicians treating a patient should work together coherently in the hospital and in the community.

A related approach is the use of continuity of care records (CCR), i.e., a set patient data that gives each clinician involved in a patient’s care information needed reduce errors and improve outcomes, such as family history, insurance, advance directives, medications, immunizations, alerts, vital signs, procedures, plan of care, and the patient’s healthcare providers.[20]

Optimal continuity of care involves several factors:
  • Contact and good communication between patients and practitioners over time help build strong trusting relationships that can improve patient adherence to treatment regimens, as well as improve monitoring of patient progress and provider awareness of any worsening symptoms or complications.
  • An integrative system approaches using policy and standards such as disease management programs and clinical pathways, as well as electronic health information systems.[21]
  • Paying case managers and/or primary care physicians to assume the responsibility for coordinating the continuity of care makes good sense.[22]



Problem: Implementation Delay


The delay between publication of clinical evidence and implementation in practice guidelines is reported to be seventeen years.[23.24]

Solution: Speed Guideline Development and Dissemination


The collaborative network the Quality though Knowledge model defines will focus on speeding guideline development and dissemination by coordinating efforts between providers and researchers.


Problem: Guidelines Do Not Consider the Mind-Body Connection


The value of guidelines designed to treat the physical illness are reduced if psychological (mental, emotional) problems presenting as or exacerbating physical illness problem are not recognized and managed. Examples include migraines, functional bowel disease, hypertension, peptic-ulcer disease, hyperthyroidism, asthma, chronic skin disorders, inflammatory disorders, and disturbances in autoimmunity.[25]

Likewise, the value of guidelines designed to treat the psychological problems are reduced if medical problems presenting as or exacerbating a mental illness/dysfunction are not recognized and managed. Examples include psychological symptoms due to poisoning[26], intracranial disorders[27]; other disorders, endocrine dysfunction[28], disease of non-endocrine organs[29], central nervous system diseases[30]; other disorders[31]; other disorders; alcohol and substance use and prescribed medications[32]; other disorders[33]; or other medical and environmental problems[34]; other disorders.

Solution: Consider the Mind-Body Connection


Practice guidelines should not ignore the mind-body connection since there is ample evidence that many biomedical problems are associated with psychosocial and emotional factors. When guidelines are being developed and validated, therefore, care should be taken to evaluate whether outcomes would be improved if patients’ physical and mental conditions are addressed.


Problem: Guidelines Do Not Address Patient Preferences


Furthermore, a patient’s personal preference can affect the value of guidelines. When, for example, research shows that two treatments options for the same condition have equal cost-effectiveness according to major clinical outcomes, there may be a tradeoff in quality of life outcomes, such as the choice between lumpectomy with radiation or mastectomy to avoid radiation. Delegating the decision to the physician alone can result in misdiagnosis of the patient’s own preference, which would adversely affect the patient’s well-being. Thus, knowing patient preference is important.[35]

Solution: Shared Decision-Making Supported by Patient Decision Aids


Patient preferences should be considered when selecting a particular practice guideline. By helping assure patients understand the potential benefits and risks, and the uncertainties of different treatment options, this shared decision-making process is helps prevent overuse of options that informed patients do not value, thereby increasing a patient’s likelihood of compliance and subsequent quality of life.

This process involves decision counseling, which can be offered by clinicians with or without formal informed-choice training, as well as trained third-party decision counselors. Using patient decision aids — evidence-based tools that use a variety of media and frameworks to give patients the information they need — can facilitate the process.[36,37]


Problem: Cookbook Guidelines are Too Rigid


A “cookbook” guideline is one dictates a course of care without consideration of providers’ (a) “explicit knowledge,” i.e., their experience and insights of which they are aware and can explain, and (b) “tacit knowledge,” i.e., their experiences and intuitions — “gut feelings” or “sixth sense” — which are tied to the actions they take, but are difficult to verbalize. Both forms of knowledge contribute to decision-making capabilities in expert practitioners, and the capacity to play a hunch and trust one’s judgment. It may help them recognize multiple means to multiple ends and thus to deviate from previously determined guidelines should circumstances alter. Novice practitioners, however, may be less flexible, tending to adhere to specific management protocols once initiated.[38]

Cookbook guidelines disregard a practitioner’s knowledge and judgments, and thus can adversely affect outcomes. This is especially true with expert clinicians.

Solution: Avoid Cookbook Guidelines


It is foolish and destructive to demand blind obedience to any particular guideline regardless of the circumstances and practitioner’s level of expertise. Instead, clinicians’ should be allowed to use their knowledge and hunches to override any recommendation, as long as they can justify their actions. And if expert clinicians make intuitive judgments that run counter to recommended protocol, they should not be penalized and, instead, learn from the outcomes in order to support or refute their gut feelings.


Problem: Guidelines May Conflict with Each Other


Lacking sufficient precision and supporting scientific evidence, guidelines from different professional bodies may conflict with each other. This confuses and frustrates practitioners.[39]

Solution: Reduce Guideline Conflicts


Once there is adequate precision in the diagnostic codes and criteria for using a particular guideline with a particular patient, there will be fewer guideline conflicts. Until then, providers should have the latitude to use their knowledge to select the guidelines they consider best for each patient.


Problem: Patient Resistance


If patients refuse to comply with a guideline’s management recommendations or are adverse to the consequences of such treatments, outcomes will likely be poor.

Solution: Involve Patients in Decisions, Consider Their Preferences, and Give Incentives for Compliance


As discussed earlier, patients should be part of the decision-making process and that their preferences should be taken into account when making treatment decisions. In addition, it may be helpful to give patients financial incentives for adherence to the health care plan and follow-up care.



Next: Problems with Today’s HIT Systems and How to Solve Them


Footnotes and References
[1] Soumerai S.B., et al. (1997) Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA, 277: 115-121.
[2] Armstrong D, Fry J, Armstrong P. (1994) General practitioners' views of clinical guidelines for the management of asthma. International Journal of Quality Health Care; 6: 199-202.
[3] Audet AM, Greenfield S, Field M. (1990) Medical practice guidelines: current activities and future directions. Ann Intern Med; 113: 709-714.
[4] Beaulieu, N. D., et al. (2003). The business case for diabetes disease management at two managed care organizations. Available at http://post.economics.harvard.edu/faculty/dcutler/papers/diabetes_case_2-3-03.pdf
[5] Shojania, K.G. and Grimshaw, J.M. (2005). Evidence-Based Quality Improvement: The State of the Science. Health Affairs, 2005; 24(1): 138-150. Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/138
[6] Porter, M. E. and Teisberg, E. O. (Jun 1, 2004). Redefining Competition in Health Care. Harvard Business Online. Available at http://www.hospicepharmacia.com/images/supporting/redefiningcompetition.pdf
[7] Cabana, M.D. (October 20, 1999) Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement. JAMA; Vol 282, No. 15. Available at http://www.acpenet.org/interact/advancedquality/Cabana.pdf
[8] Leatherman, S. et al. (2003) The Business Case for Quality: Case Studies and Analysis. Health Affairs 22(2):17-30. Available at http://www.medscape.com/viewarticle/451074
[9] Verstraete, M. (2002) How to increase the impact of clinical guidelines on medical practice. European Review, 10: 545-553 Cambridge University Press
[10] Woolf, S. H., et al. (1999) Potential benefits, limitations, and harms of clinical guidelines. BMJ 318 (20). Available at http://bmj.bmjjournals.com/cgi/reprint/318/7182/527.pdf
[11] Shojania, K.G. and Grimshaw, J.M. (2005). Evidence-Based Quality Improvement: The State of the Science. Health Affairs, 2005; 24(1): 138-150. Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/138
[12] Current Validity of AHRQ Clinical Practice Guidelines. (2002). Available at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.3762
[13] Available at http://www.wedi.org/cmsUploads/pdfUpload/eventsPresentationInformation/pub/ICD-10_Brooks.pdf
[14] Slee, V.N. (2001). The Endagered Medical Record. Available at http://www.tringa.com/hccc_web.pdf
[15] Slee, V.N., et al. (2004). Input of Diagnoses in the Medical Information System. Available at http://tringa.com/dxinput.pdf
[16] Conner, M. G. Criticism of America's Diagnostic Bible - The DSM. Available at http://www.oregoncounseling.org/Diagnosis/CriticismOfDSM.htm
[17] Kolbasuk McGee, M. (February 13, 2006). A Pill, A Scalpel, A Database: Health care is embracing IT to analyze a glut of medical data, find new cures, and provide more-personalized treatment. InformationWeek. Available at http://www.informationweek.com/showArticle.jhtml;jsessionid=DFGBPHXQ1KM42QSNDBECKHSCJUMEKJVN?articleID=179103437
[17a] ABC Solutions web site at http://www.abccodes.com/ali/home/
[17b] Slee, V.N., Slee, D., & Schmidt, J. (2005). The Tyranny of the Diagnostic Code. NC Medical Journal; 66(5). Available at http://www.ncmedicaljournal.com/sept-oct-05/Slee.pdf
[18] Biem, H.J. & Hadjistavropoulos, H.D. (January 31, 2004). Managing Continuity of Care through Integrated Care Pathways: A Study of Atrial Fibrillation and Congestive Heart Failure. Canadian Health Services Research Foundation. Available at http://www.chsrf.ca/final_research/ogc/biem_e.php
[19] Continuity of care: A communication protocol for Victorian public maternity services and the Maternal Child Health Service. The Community Care Division Victorian Government Department of Human Services, Melbourne, Victoria. 2004. Available at http://www.office-for-children.vic.gov.au/commcare/ccdnav.nsf/fid/-A6E50FEE19CBFC79CA256F530081B6C0/$file/mch_continuity_care_2004.pdf
[20] Gater, L. (January 30, 2006). Building EMR Portability With The Continuity of Care Record. Radiology Today; 7 (2), 14. Available at http://www.radiologytoday.net/archive/rt13006p14.shtml
[21] Biem, H.J. et al. The Continuity of Care Challenge; Breaks in Continuity of Care and the Rural Senior Transferred for Medical Care under Regionalization. International Network of Integrated Care. Available at http://www.integratedcarenetwork.org/publish/articles/000036/article_print.html
[22] Bagley, B. (August 1998). Hospitalists and the Family Physician. American Academy of Family Physicians; Editorial. Available at http://www.aafp.org/afp/980800ap/edit.html
[23] Balas, E. A., & Boren, S. A. (2000). Managing clinical knowledge for health care improvement. In J. Bemmel & A. T. McCray (Eds.), Yearbook of Medical Informatics (pp. 65-70). Stuttgart: Schattauer Verlagsgesellschaft mbH.
[24] Clancy, C. M., & Cronin, K. (2005). Evidence-based decision making: Global evidence, local decisions. Health Affairs, 24(1), 151-162. Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/151
[25] Disturbances of physiology that are related in some way to situational/psychological conditions, but without actual permanent end-organ damage, include migraines, functional bowel disease and types of chronic pain. Disturbances where actual physiological and psychological pathologies are evident include hypertension, peptic-ulcer disease, hyperthyroidism, asthma and chronic skin disorders. Serious physiological disorders that tend to appear or flare up with significant life changes and stress include disturbances in autoimmunity. Illnesses such as coronary heart disease and cancer that may be helped with adjunctive treatments which promote changes in patients' behaviors (e.g., improve eating, sleeping, and exercise habits) and psychological states (e.g., reducing resentful anger and stress-proneness). Maladaptive behaviors and attitudes that have obvious deleterious health effects on oneself and/or others, such as substance and alcohol abuse, anorexia, bulimia, obesity, smoking, unsafe sex, recklessness, suicidal tendencies, and abusive behavior toward others.
[26] Poisons including: Carbon monoxide, Lead, Mercury, Manganese, Aluminum, Arsenic
[27] Intracranial disorders including: cerebral anoxia, cerebral lipoidosis, cerebral trauma (esp. concussion), cerebroneoplasms, cerebrovasular disorders/diseases, epilepsy, headaches, hydrocephalus, encephalitis, herpes simplex encephalitis, meningitis; intracranial tumors, lateralized focal brain lesion, thalamotomy
[28] Endocrine dysfunctions including: Addison’s disease (hypoadrenalism), carcinoid syndrome, Cushing's syndrome (hyperadrenalism), diabetes mellitus, hyperaldosteronism, hyperinsulinism, hypoglycemia, hypoglycemia - posthypoglycemic states, hyperthyroidism, hypothyroidism, hypoparathyroidism, menses-related dysfunction (menopausal), pancreas, parathyroid, pheochromocytoma, pituitary, premenstral syndrome, testosterone level-elevated, testosterone level-deficient, virilization disorder of females
[29] Nonedocrine organ disesases including: cardiovascular system - cardiopulminary disease, cardiovascular accident, anemia, arrhythmias, angina pectoris, cardiac failure, coronary artery disease (causes myocardial ischemia), congestive heart failure, essential hypertension (high blood pressure), hyperactive beta-adrenergic state, hypotension, inflammatory disease of blood vessels, mitral valve prolapse, myocardial infarction, multi-infarct dimentia, paradoxical atrial tachycardia, transient ischemic attack, vasomotor syncope • deficiency diseases - folate deficiency, vitamin b-y2 deficiency, vitamin c deficiency, niacin deficiency (pellagra), thiamin deficiency (korsakoff's syndrome), electrolyte imbalance of any cause • gastrointestinal system - mucous colitis, spastic colitis, ulcerative colitis, irritable bowel (colon) disease, pruritus ani, pylorospasm, duodenal ulcer, gastric ulcer, peptic ulcer, regional enteritis (ileitis), hypercalcemia • kidney & urinary tract - dialysis dimentia, hemodialysis, renal disease, uremic encephalopathy (uremia) • liver - hepatic encephalopathy • pulmonary - asthma, alveolar hypoventilation syndrome, carbon dioxide narcosis, hyperventilation, hypoxia, pulmonary embolus, pulminary insufficiency, respiratory encephalopathy, systemic infections, systemic neoplasms
[30] Central nervous system diseases including: Alzheimer's disease, CNS infections, CNS lesions, Creutzfeldt-Jakob disease, Faby's disease, Fahr's disease, Hallervorden-Spatz disease, AIDS & Human Immunodeficiency Virus (HIV), Huntington's (chorea) disease, Meniere's disease, multiple sclerosis, Neurosyphilis, Parkinson's disease, Pick's disease, spinocerebellar degerneration, supranuclear palsy (progressive), Wilson's disease, Wernicke-Korsakoff syndrome
[31] Other illnesses including: allergy (other than bronchial asthma), anaphylaxis, angioneurotic edema, botulism, cancer, chronic fatigue syndrome, chronic pain syndrome, febrile illnesses, hepatolenticual degerneration, herpes simplex - genital, homocystinuria, kleine-levin syndrome, klinefelter's syndrome, metachromatic leudodystrophy, mononucleosis, nocturnal myoclonus and restless legs syndrome, narcolepsy, general paresis, pneumonia-viral & bacterial, posthepatitis syndrome, porphyria, postoperative states, postpartum mood disorders, sacroiliac pain (lower back pain), sarcoidosis, sleep apnea syndromes, systemic malignancies, tuberculosis, opthamological disorders, optic nerve disesase, auditory nerve disease, middle and inner ear disorders
[32] Prescribed medications including: analgesic & anti-flammatory drugs, antihisimines, antialcohol drugs, antibacterial & antifungal drugs, anticholingeric agents, anticonvulsants, antihypertensive & cardiac agents, antineoplastic drugs, antituberculosis drugs, hormones & steroids, neurological agents, antidepressants, mood stabilizers, neuroleptics (antipsychotics), anxiolic angents, hypnotics/sedatives, psychostimulants
[33] Alcohol and substance use and prescribed medication symptoms including: delirium, dementia, organic personality syndrome, hallucinosis, hallucinations, delusions, psychotic symptoms, suspiciousness; paranoia, depersonalization, derealization, percpetual illusions/dysfunction, memory impairment; amnesia, confusion; disorientation, anxiety, panic, tense; low frustration tolerance; nervousness; psychomotor agitation; restelessness, concentration & attentional deficit, hypervigilence, irritability, blunt affect, impaired judgement, stereotyped, repetitive behaviors, disinhibition of anger and/or aggressive impulses; billigerence, hyper; excitation; excitability; inexhaustability; manic, mania, euphoic feelings; grandiosity, dysphoria; sadness; ahedonia; malaise; depression, apathy, mood swings; mood lability, insomnia (difficulty falling or staying asleep), hypersomnia; excessive sleeping, drowsiness; sedation; daytime sleepiness, muscle weakness; fatigue; lethargy, psychomotor retardation, male impotence, ejaculation difficulty, inhibited sexual desire, female orgasm dysfunction; anorgasmia in females, disinhibition of sexual impulses, bulimia, anorexia, decreased appitite or weight loss, increased appetite or weight gain, diuresis (increased excretion of urine), gi distress; nausea, vomiting; diarrhea, lacrimation (discharge of tears), rhinorrhea (discharge of thin nasal mucus), dizziness; lightheadedness; feeling faint, ataxia; incoordination; unsteady gait; poor balance, muscle rigidity; orthostatic hypotension (erect posture), stiff or sore muscles or neck, muscle twitching; tremors; shakiness; trembling, bradyskinesias (impaired voluntary movement), dystonias (impaired muscle tone), depressed reflexes, numbness or diminished pain responsiveness, flushed face, chest pain, palpitations, tachycardia (high heart rate), cardiac arrhythmias, bradycardia (decreased heart rate), hypertension (elevated blood pressure), lowered blood pressure, blurring of vision, diplopia (perception of two images of a single ojbject), nystagmus (involuntary, rapid, movement of the eyeball), pupillary dilation, conjunctival injection (bloodshot eyes), breathing difficulty; shortness of breath, persperation; sweating, fever, chills, headaches, seizures, stupor or coma, vivid unpleasant dreams, slurred speech, dysarthria (poor muscular control causes speech articulation difficulties), rambling flow of thought and speech; rapid or excessive speech, skin rash or itching, dry mouth, allergies, psychosomatic
[34] Other medical and environmental problem including: head injury, birth trauma, childhood ear infections, developmental milestone delays, exposure to hazardous or toxic substances, substance use by mother during pregnancy, tobacco use by mother during pregnancy, diet/exercise routine
[35] Wennberg, J.E. Commentary: Evidence-based Medicine and Practice Variations. Available at http://www.uhftips.org/Clin.EvidenceCommentary%20JW.doc
[36] O’Connor, A.M., et al. (2004). Modifying Unwarranted Variations in Health Care: Shared Decision Making Using Patient Decision Aids. Health Affairs. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.var.63v1
[37] Woolf et al. (2005). Promoting Informed Choice: Transforming Health Care To Dispense Knowledge for Decision Making. Annuals of Internal Medicine; 143: 293-300. Available at http://www.annals.org/cgi/content/abstract/143/4/293#FN
[38] Journal of Emergency Primary Health Care. (2003) Vol.1, Issue 3-4. http://www.jephc.com/uploads/990057.pdf
[38] Feder G. (1994) Management of mild hypertension: which guidelines to follow? BMJ;308:470­1.

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