Jonathan Lomas

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Groups of aphasic patients and their spouses generated a series of communication situations that they felt were important in their day-to-day life. Using criteria to ensure that the situations were generalizable across people, times, and places, we reduced the number of situations to 36 and constructed an index that allowed the significant others of 11 recovering and 11 stable aphasic individuals to rate their partners' performance in the situations on two occasions 6 weeks apart. These data were then used to evaluate the psychometric properties of the Communicative Effectiveness Index (CETI) as a measure of change in functional communication ability. Further application of a generalization criterion reduced the final index to 16 situations. Results showed the CETI to be internally consistent and to have acceptable test-retest and interrater reliability. It was valid as a measure of functional communication according to the pattern of correlations found with other measures (Western Aphasia Battery, Speech Questionnaire, and global ratings). Finally, it was responsive to functionally important performance change between testings. Further research with the CETI and its usefulness for clinicians and researchers are discussed.

material. The written description of the interventions had 715 words. Our diagram (fig 3) shows immediately the cumulative nature of the experimental interventions.