Can 'Cascades' make guidelines global?

Why are guidelines in medicine so important today? What role do they have? Why and how did the World Gastroenterology Organization (WGO) choose a global focus? What does this mean for guidelines? These are the underlying questions addressed by our article. We argue that the addition of 'Cascades' to guidelines will increase their impact in large parts of the world. By so doing, we hope to add a new dimension to the 'knowledge into action' debate. A number of illustrations shows how raised expectations and resource restrictions pose - or should pose - an enormous challenge for guideline makers. Furthermore, the emphasis on evidence also creates problems for guideline making. If resources are limited it is unlikely gold-standard technologies are available. We believe Cascades can help. A Cascade is a selection of two or more hierarchical diagnostic or therapeutic options, based on proven medical procedures, methods, tools or products for the same disease, condition or diagnosis, aiming to achieve the same outcome and ranked by available resources. The construction of such a cascade is a hazardous intellectual journey that goes, to some extent, against established practice. But lives can be saved by matching options for diagnosis and treatment to available resources. While the optimal strategy, defined through an evidence-based approach, should always be the goal, one must be aware of the resource limitations that confront our colleagues in certain parts of the world and we should endeavour to work with them in the guideline development process to develop strategies that are clinically sound yet economically feasible and dacceptable to their populace.