Adapting a National Guideline for Local Use: A Comparative Case Study in a US and an Israeli Health Maintenance Organization

Objectives: We compared the way a US and an Israeli health maintenance organization (HMO) used the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (the JNG V) in developing a hypertension guideline. Methods: Comparative case study. We describe and contrast the two HMOs, the social contexts in which they function, their motivations for creating a local guideline and their guideline development processes. We then compare the two HMO guidelines with each other and with the JNC-V. Based on this analysis, we offer provisional answers to some key concerns raised by local adaptations of national or international guidelines. These include whether adaptations will reflect local cost-containment concerns in ways that could threaten quality of care, whether guidelines constitute a threat to physician autonomy and the relationship between local adaptations and the evolution of national or international guidelines. Results: The HMO guidelines differed substantially, and in similar ways, from the JNC-V in format, coverage and emphasis of topics. They differed from it minimally, but also in similar ways, in the content of their recommendations. Each HMO guideline ‘improvised’ on the JNC-V in ways that differed to reflect local needs and objectives but did not significantly distort the original. Quality of care considerations appeared to predominate over cost considerations, and we found no evidence that guidelines threatened physician autonomy. Conclusions: Local adaptations may function as part of the iterative process through which national or international guidelines evolve in ways more suitable for potential local use.