This paper describes the development and successful implementation of an evidence-based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses.

Longitudinal patient–provider relationships are a cornerstone of primary care. For many prevention services, better continuity of provider has been associated with better adherence to recommended practice. Our objective was to examine the relationship between continuity of care and chlamydia screening in adolescent and young women, a preventive service where large performance gaps exist.The study population included 4117 sexually active women aged 14–25 years continuously enrolled at a large U.S. HMO. Administrative data from 2000 to 2002 were used to document chlamydia testing, provider continuity, and selected covariates. We used logistic regression to examine the relationship between provider continuity and chlamydia testing after controlling for potential confounders.57.2% of eligible young women received a chlamydia test over the 2-year period. After controlling for utilization and other confounders, we found women in the lowest continuity of care quartile had 41% greater odds of being tested than those in the highest quartile (OR 1.41, 95% CI 1.14–1.76).For adolescents and young women, the likelihood of testing for chlamydia was reduced when care was concentrated with a usual provider. Potential implications for health service delivery are discussed.

Group Health Cooperative of Puget Sound has developed a model for evaluating and improving clinical practice based on an explicit, evidence-based approach. It is designed to identify gaps between current and optimal practices, and to bring about changes in physician behavior so that health care outcomes (health status, patient satisfaction, provider satisfaction, cost/utilization) are maximized. This model stresses the importance of a rigorous process in looking objectively at evidence in working to improve outcomes. Discrete tools have been developed which help teams move successfully from problem identification to the ongoing evaluation and improvement of a new clinical practice.

In response to a marked increase in the use of an available test, Group Health Cooperative of Puget Sound (GHC) evaluated the use of prostatic specific antigen (PSA) as a screening test for prostate cancer. A project team reviewed the literature and determined that PSA did not meet GHC's criteria for screening. An implementation team then developed a comprehensive program to educate staff, facilitate practice change, measure outcomes and provide continuing feedback to physicians. These efforts are described and preliminary reports reported.

Following the National Cholesterol Educational Program's (NCEP) 1988 screening and treatment recommendations, an educational and behavior-change program at Group Health Cooperative of Puget Sound (GHC) was developed to guide the use of lipid-lowering drugs within the larger context of cardiac risk reduction. The program has been successful in advancing a rational program to enhance care and manage costs of the use of lipid-lowering agents at GHC. Cost savings have been significant over the past two years. The educational design of the program includes training and ongoing education of a core group of "lipid gurus," who educate colleagues in area medical centers in a rational approach to hyperlipidemia. Patient education and patient participation in decision-making was emphasized. Program evaluation has demonstrated that physicians and patients are satisfied with the program, and inappropriate drug expenditures have been prevented. Key elements of the program include a critical review of outcome studies in the medical literature, use of information systems, algorithms and written materials organized into a well-designed, ongoing educational program, and development of a core group of physicians and pharmacists to administer the program at the clinic level.