Development, use, and evaluation of clinical practice guidelines.

The development and use of practice guidelines, if framed as recommendations for best practices in the prevention, diagnosis, treatment, and management of occupationally related health concerns and disability, can improve the quality of occupational medical practice and worker health and well being. Adherence to guidelines should improve the efficiency and effectiveness of prevention, care, and disability management by reducing the present wide variance in practices and then by moving the mean or median of process and outcome statistics toward recommended levels. The information developed for guidelines can also be used for patient discussion and expectation management. Practicing in evidence-based, agreed-upon ways should also make occupational medical practices more defensible. Guidelines should be explicit, be based on a review of the available evidence and benefits vs risks, have clear medical logic, link findings to diagnosis to treatment ot prevention, be time-based, and avoid recommending unproven approaches as a last resort. If possible, they should be reviewed and tested for usability. Guidelines that start with common occupational health concerns are best suited to prevention and outpatient care, because patients present in this way. The contents of a useful occupational health guideline would include a statement of purpose and scope, the method of development; the authors' and reviewers names and affiliations; an analysis of the specificity, sensitivity, and predictive power of mechanisms of illness or injury, symptoms, signs and tests; findings that point to a serious or emergent condition requiring immediate referral or treatment; diagnostic criteria; and initial treatment, including work with the patient in a therapeutic partnership. The guideline should also present information on factors known to be associated with work, and predictors of delayed recovery. Disability-duration statistics and methods of matching job requirements with worker abilities are also helpful. Guidelines should then outline reassessment of those patients whose health concerns remain after a reasonable recovery period. The recommendations should again be evidence-based and conform to the other attributes listed above. A discussion of management after reassessment, including behavioral referral, further testing, and procedures, is also quite useful. Recommendations for restoration of function and return to work complete guidelines focused on diagnosing, treating, and resolving activity limitations among workers. Simply developing and publishing guidelines has not resulted in improvement in practice. However, if used as the basis for peer-group interactions and actions by occupational health opinion leaders, guidelines can contribute to marked improvements in quality, worker satisfaction, and worker health.