The paradox of guideline implementation: how AHCPR's depression guideline was adapted at Kaiser Permanente Northwest Region.

BACKGROUND: To ensure implementation, the Agency for Health Care Policy 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 convenience, credibility, audience, purpose, and context. For example, in their roles as representative consumers, committee members perceived that the AHCPR guideline, although addressed to primary care clinicians, was actually written from a psychiatric perspective and based on a psychiatric literature not relevant to primary care. COMPARISON OF THE GUIDELINES: Although the guidelines differ dramatically in length and format, coverage, emphasis, and organizing principle, substantive conflict between the two guidelines' recommendations is minimal. For example, the emphasis on medication is greater in the adaptation, which adds considerable original material of 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 to treat depression. DISCUSSION AND IMPLICATION: Translation of science-oriented national guidelines into user-oriented documents tailored to local audiences and settings can add great value to the guideline development process without sacrificing science-derived integrity-and is probably essential to successful implementation.