How primary health care professionals and residents assess issues related to the oral health of older persons?

doi: 10.1111/j.1741‐2358.2009.00355.x
How primary health care professionals and residents assess issues related to the oral health of older persons? Background and objectives: It is known that older persons need integrated primary health care. However, oral health may not be a frequent concern of multi‐professional teams taking care of older persons. The aim of the present study was to evaluate knowledge and practices related to oral health care, as reported by professionals and residents in a primary health care service. Material and methods: One hundred and seventy‐three health professionals and residents were assessed in this cross‐sectional study by means of a structured questionnaire containing questions pertaining to oral health practices and beliefs. Participants were grouped based on their professions into “primary health care dentists” or “other primary health care professionals” and based on their working status into “permanent team” or “residents”. Results: Permanent team members (other professionals) assessed and recommended dental care more frequently than residents. Permanent team members (other professionals) also reported that they felt they were able to inform older patients in respect to oral health‐related issues more frequently than did residents (68.7% vs. 31.3%, respectively). Conclusion: Oral health‐related knowledge and beliefs were frequent among non‐dentists primary health care workers, suggesting that primary health care which integrates oral health represents an attainable goal.     

Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre

H. Stokes‐Lampard, S. Wilson, C. Waddell and L. Bentley Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre Objectives: To examine temporal trends in the use of vault cytology tests in primary and secondary care and the demographics of those women tested. Methods: Retrospective analysis of routinely collected data concerning women who had a vault cytology test processed during a 10‐year period (1 April 1995 to 31 March 2005) at Birmingham Women’s NHS Foundation Trust. Results: A total of 8457 vault cytology tests from 3164 women (range 1–17 tests, median = 2) were processed, representing approximately 2% of the cervical cytology workload of the Department of Cytopathology at Birmingham Women's Hospital. There was a significant reduction in annual numbers processed (Pearson correlation ?0.958, P < 0.001). Significant abnormalities (mild dyskaryosis or worse) were detected in 4.5%, with malignancy being detected in <0.1%. The unsatisfactory cytology test rate was 10.7% overall. There was a reduction in the numbers of vault cytology tests coming from the community, hospital outpatient clinics and operating theatres over time (χ² for linear trend = 139.53, 9 d.f., P < 0.0001). Tests originating from community settings had the lowest disease detection rates: no malignancies and only two severe abnormalities were detected from almost 4000 primary care samples; abnormal results represented 2.8% (n = 113), of which the majority (n = 73) were borderline results. All cancers (n = 8) were detected in samples taken in gynaecology and colposcopy clinics. Conclusions: Vault cytology test usage appears to be reducing, particularly from outpatient clinics and primary care. Community detection rates are very low. Further research is required to establish the true costs and benefits of vaginal vault cytology.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

Cervical smear abnormalities in the United Arab Emirates: a pilot study in the Arabian Gulf

OBJECTIVE: To gather epidemiologic data on cervical abnormalities and make recommendations pertaining to a national cervical screening policy in the United Arab Emirates (UAE). STUDY DESIGN: A cross-sectional survey of patients and physicians in the UAE with regard to cervical cytology was carried out. Knowledge, attitudes and practices (KAP) of a group of female primary care physicians on cervical cytology were assessed by a self-administered questionnaire. Pap smears and Chlamydia testing were offered to women attending selected primary care centers and secondary health care facilities. RESULTS: Results of Chlamydia prevalence and KAP were published elsewhere; this report addresses the cytologic aspects of this study. There were 2,013 smears collected from primary health centers and 2,042 from secondary care. The overall rate of cervical screening among women in this survey was 85.5% in primary care and 77% in secondary care. The proportion of unsatisfactory smears was < 5%. The prevalence of cervical abnormalities according to the Bethesda System 2001 was 3.6%. There were 9 (primary care) and 21 (secondary care) cases of low grade squamous intraepithelial lesion (LSILs), for a prevalence of 0.77%. There were 4 primary care and 17 secondary care cases of high grade squamous intraepithelial lesion (HSIL), for a prevalence of 0.54%. The combined prevalence for LSIL and HSIL is 1.32%. There were 3 cases of glandular abnormalities. The atypical squamous cells of undetermined significance/SIL ratio was 1.71. No cases of squamous cell carcinoma were detected. No tissue follow-up information is available. The prevalence of cervical abnormalities is low in the UAE. We first recommend the institution of a more organized approach to opportunistic screening in the UAE with appropriate clinical follow-up rather than the immediate launch of a cervical mass screening program.     

A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol

ABSTRACT: BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. DESIGN: A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD. The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities. The primary outcome measure is health-related quality of life, assessed with the St George's Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients' randomization groups. DISCUSSION: This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care. Trial registration ACTRN12610000592044\     

An audit of cervical cytology in HIV‐positive women

O. E. O. Hotonu, J. Hussey, M. S. T. Basta, V. Wadehra, P. Cross and M. L. Schmid
An audit of cervical cytology in HIV‐positive women Objective: To investigate whether a cohort of human immunodeficiency virus‐positive (HIV+) women were having annual cervical cytology as recommended by the English National Health Service cervical screening programme (NHSCSP) guidelines. Methods: An audit of cervical cytology in an HIV+ cohort of 187 women by obtaining their last cervical cytology result and recall from local cytology services. Results: Of the 187 women in the audit, two were ineligible, leaving 185 women, 167 (90.3%) of whom were aged 25–64 years and eligible for screening. Of the 185 women, 126 (68.1%) had a cytology history, 50 (27%) had never had cervical cytology and nine (4.9%) had inadequate details to ascertain whether or not they had a cytology history. Of the 126 with a cytology record, 34 (27%) had a current cytological abnormality, which was low grade in 25 (19.8%) and high grade in nine (7.1%). Among women aged 25–64 years attending the clinic, these percentages were significantly higher than expected for England as a whole (P < 0.001). Of 126 women with a cytology record, 29 (23%) were overdue for their recall date and of these the previous test was abnormal in 14 (48.3%). Cytology tests were taken within the community setting in 61 (48.4%), whereas 65 (51.6%) were seen either at an HIV sexual health clinic or were under colposcopy follow‐up. Of 91 women with negative cytology only 50 (54.9%) were recommended for repeat in 12 months. Conclusion: This audit demonstrates a high rate of cytological abnormalities among HIV+ women compared with the screening population at large. Implementation of NHSCSP guidelines has been difficult and requires improved care pathways between HIV clinics, primary care and laboratories.     

Would primary health care workers give appropriate dietary advice after cholesterol screening?

The purpose of this study was to obtain information on the dietary knowledge of primary health care workers and on their ability to apply this knowledge in practice. A total of 128 primary health care workers (53 general practitioners and 61 nurses) in 12 practices and 14 primary care facilitators were surveyed by questionnaire between December 1987 and June 1988. All of the practices were participating in a project to promote prevention in primary care and offered health checks designed to identify and deal with cardiovascular risk factors. The questionnaire focused on issues related to managing patients with moderate hypercholesterolaemia. The results of the study showed some important gaps in the health workers'' knowledge--for example, only 91 understood that dietary intake of polyunsaturated fatty acids as a proportion of total fat intake should be increased in a diet designed to reduce serum lipid concentrations. Appreciable gaps in their ability to give practical and appropriate dietary advice were also identified: 35 gave advice that would have led to the patient losing weight (although his history indicated that he was not overweight), and 27 gave only negative advice, offering no suggestions about substituting healthy foods for unhealthy ones. The demand for primary health care workers to give dietary advice is increasing and is likely to increase further if a national screening programme for hypercholesterolaemia is recommended. The results of this survey point to a need for improved nutritional education and training in dietary counselling for general practitioners, nurses, and primary care facilitators.     

Health professionals' overestimation of knowledge on snakebite management,a threat to the survival of snakebite victims—A cross-sectional study in Ghana

BackgroundAccording to the World Health Organization, snakebites, a common occupational hazard in developing countries accounts for an annual loss of between 81,000 and 138, 000 lives following 5 million bites of which 2.7 million results in envenomation. Since snakebite-associated morbidity and mortality are more prevalent in agricultural economies such as Ghana, health professionals should be optimally knowledgeable on how to manage the incidence of snakebites. Lack of knowledge or overestimation of a professional''s knowledge can affect heath delivery especially for emergencies such as snakebites. The three rurally situated Tongu districts in South-Eastern Ghana with agriculture as the major source of livelihood for their inhabitants, are prone to snakebites. This study, therefore, brings up the need to assess whether the health professionals in these districts are well-equipped knowledge-wise to handle such emergencies and whether they can rightly estimate their knowledge with regards to snakebite management.Methodology/Principal findingsData was collected using a de novo semi-structured questionnaire administered through google form whose link was sent via WhatsApp to 186 health workers made up of nurses, midwives, physician assistants, medical doctors, pharmacists, and pharmacy technicians. This data was analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Association between variables was determined using the appropriate tools where necessary, using a confidence interval of 95% and significance assumed when p ≤ 0.05. This study found male health workers significantly more knowledgeable about snakebite management (11.53±5.67 vs 9.64±5.46; p = 0.022) but it was the females who overestimated their knowledge level (27.9% vs 24.1%). The medical doctors exhibited the best knowledge on snakebite management with the registered general nurses least knowledgeable. Although most professionals overestimated their knowledge, the registered general nurses were the worst at that (53.7%). Overall knowledge of health care professionals on snakebite management was below average [10.60±5.62/22 (48.2%)] but previous in-service training and involvement in the management of snakebite were associated with better knowledge. Respondents who had no previous training overestimated their knowledge level compared to those who had some post-qualification training on snakebite management (38.1% vs 7.5%). The greatest knowledge deficit of respondents was on the management of ASV associated adverse reactions.ConclusionHealth workers in rural Ghana overestimated their knowledge about snakebite management although their knowledge was low. Training schools, therefore, need to incorporate snakebite management in their curriculum and health authorities should also expose health workers to more in-service training on this neglected tropical disease.     

P‐4TRANSFORMATION ZONE COMPONENT IN LIQUID BASED CERVICAL CYTOLOGY

Introduction: Quality assurance guidelines for the UK cervical screening programme recommend that more than 80% of cervical samples from women aged 20–50 years should contain adequate numbers of Transformation zone (TZ) cells i.e. 10 or more endocervical or squamous metaplastic cells. This study was conducted to assess the frequency of TZ component in Liquid Based Cytology (LBC) both for ThinPrep (TP) and SurePath (SP) LBC. Also to assess the degree to which this is recorded by individual screeners and to determine the percentage of samples with evidence of TZ component for the different smear takers. Method: All LBC cervical specimens received at a tertiary cytology centre in the year 2004 from women aged 20–50 years were included in the study. Evidence of TZ sampling was recorded as: TP = TZ present (10 or more TZ cells)TA = TZ absentTS = TZ scanty (less than 10 TZ cells)TN = atrophic smears, TZ cells not recognisable Results: The total number of LBC cervical cases was 7445. TP = 4300 (mostly primary care) and SP = 3145 (mostly colposcopy). Overall TZ sampling rate in LBC was 82%. TP = 77.17%; SP = 88.24%. When scanty TZ was included, the standard was met for both systems (TP = 93.7%; SP = 88.24%). Presence/absence of TZ component was recorded in 6370 cases (85.1%); range 0%–97.79%. 56.7% of smear takers achieved the minimum standard for TZ sampling. Discussion: The percentage of ThinPrep samples containing adequate TZ cells was 77.17% compared to SurePath, which was 88.24%. This may be due to different patient populations i.e. primary care versus colposcopy. Screeners recorded TZ sampling in approximately 85% of samples. 56.7% of smear takers met the standard for TZ sampling.     

P-27ATYPICAL GLANDULAR CELLS ON SMEAR – AGE RELATED IMPLICATIONS AND MANAGEMENT

Introduction:  There is ongoing debate about the terminology used in the classification of dyskaryosis, including whether BNA smears should be classified according to whether koilocytes are present or not. We explored the effect of koilocytosis in the management experiences and clinical outcomes of women with a single BNA smear.
Methods:  This study includes 410 women aged 20–59 years, resident in Tayside who had an 'baseline' BNA smear between 31/10/1999 and 31/10/2002 who were eligible for the TOMBOLA trial but who did not participate. Recommended follow-up for these women was a repeat smear in six months. Up to three-years follow-up data was collected on subsequent cytological smears, colposcopy examinations and any related histology. The baseline smear was re-read for the presence or absence of koilocytes. Women were classified according to their clinical outcomes during their three years.
Results:  47% (192/410) of women were classified as having koilocytosis at baseline. The mean age was lower among these women (25 years) compared to those without koilocytosis (35 years). 55% (105/192) of women with koilocytosis at baseline had one or more negative smears and no further abnormal smears, compared to 63% (137/218) of those without koilocytosis, the difference was not statistically significant. 28% (53/192) of women with koilocytosis at baseline were referred to colposcopy after subsequent low-grade or high-grade smears compared to 19% (42/218) of those without koilocytosis; the difference was statistically significant. 14% (27/192) of women with koilocytosis at baseline were diagnosed with CIN2/3 or worse during follow-up compared to 10% (21/218) of women without koilocytosis; the difference was not statistically significant.
Discussion:  Our results suggest that the presence or absence of koilocytosis has little impact on the clinical outcomes of women with a BNA smear.     

An Evaluation of the Implementation of Maternal Obesity Pathways of Care: A Mixed Methods Study with Data Integration

ObjectivesMaternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives.ResultsStudy 1: Four themes were identified: women’s overall (positive and negative) views of the pathways; knowledge and understanding of the pathways; views on clinical and weight management advice and support; and views on the information leaflet. Key results included positive views of receiving additional clinical care, negative experiences of risk communication, and weight management support was considered a priority. Study 2: Healthcare professionals felt the pathways were worthwhile, facilitated good practice, and increased confidence. Training was consistently identified as being required. Healthcare professionals predominantly focussed on women’s response to sensitive obesity communication. Study 3: There was good compliance with antenatal clinical interventions. However, there was poor compliance with public health and postnatal interventions. There were some strong areas of agreement between component studies which can inform future development of the pathways. However, disagreement between studies included a lack of shared priorities between healthcare professionals and women, different perspectives on communication issues, and different perspectives on women’s prioritisation of weight management.ConclusionThe differences between healthcare professionals’ and women’s priorities and perspectives are important factors to consider when developing care pathways. Shared perspectives could help facilitate more effective implementation of the pathway interventions that have poor compliance.     

Weaknesses in primary health care favor the growth of acquired syphilis

Acquired syphilis is a sexually transmitted infection that affects the general population and has been growing in recent years in many countries. A study was developed aiming to analyze the trends of acquired syphilis associated with sociodemographic aspects and primary health care in Brazil, in the period from 2011 to 2019. This study used secondary data from the national notification systems of the 5570 Brazilian cities and a database of 37,350 primary health care teams, as well as socioeconomic and municipal demographic indicators. The trends of acquired syphilis at the municipal level were calculated from the log-linear regression, crossing them with variables of primary health care and sociodemographic indicators. Finally, a multiple model was built from logistic regression. 724,310 cases of acquired syphilis have been reported. In primary care units, 47.8% had partial coverage and 74.1% had health teams with poor or regular scores. 52.6% had rapid test for syphilis partially available. Male and female condoms are available in 85.9% and 62.9% respectively and 54.4% had penicillin available in the health facility. The increase in trends of acquired syphilis was associated with better availability of the rapid test; lower availability of male condoms; lower availability of female condoms; lower availability of benzathine penicillin; partial coverage of the teams in primary health care; limited application of penicillin in primary health care; higher proportion of teams classified as Poor/Regular in primary health care; higher proportion of women aged 10 to 17 years who had children; higher HDI; higher proportion of people aged 15 to 24 years who do not study, do not work and are vulnerable; and population size with more than 100,000 inhabitants. The following variables remained in the multiple model: not all primary health care teams apply penicillin; higher proportion of primary health care teams with poor/regular scores; population size >100000 inhabitants; partially available female condom. Thus, the weakness of primary health care linked to population size may have favored the growth of the acquired syphilis epidemic in Brazilian cities.     

A risk adjusted cost‐effectiveness analysis of alternative models of nurse involvement in obesity management in primary care

Objective:

Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost‐effectiveness (RAC‐E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinical‐based activities.

Design and Methods:

Linked, routinely collected clinical data describing clinical outcomes (weight, BMI, and obesity‐related complications) and resource use (primary care, pharmaceutical, and hospital resource use) were collected. Potential confounders were controlled for using propensity weighted regression analyses.

Results:

Relative to low level involvement of practice nurses in the provision of clinical‐based activities to obese patients, high level involvement was associated with lower costs and better outcomes (more patients losing weight, and larger mean reductions in BMI). Excluding hospital costs, high level practice nurse involvement was associated with slightly higher costs. Incrementally, the high level model gets one additional obese patient to lose weight at an additional cost of $6,741, and reduces mean BMI by an additional one point at an additional cost of $563 (upper 95% confidence interval $1,547).

Conclusion:

Converted to quality adjusted life year (QALY) gains, the results provide a strong indication that increased involvement of practice nurses in clinical activities is associated with additional health benefits that are achieved at reasonable additional cost. Dissemination activities and incentives are required to encourage general practices to better integrate practice nurses in the active provision of clinical services.     

An audit of colposcopy appointment processes in women with abnormal cervical cytology

C. Kietpeerakool, M. Manopunya, P. Phuprasertsak, T. Jaijit and J. Srisomboon An audit of colposcopy appointment processes in women with abnormal cervical cytology Objectives: This study was conducted to audit the waiting times and default rates of colposcopy using the standard requirements of the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. Methods: The records of 291 women with abnormal cervical smears referred to the colposcopy clinic between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed. Results: The proportion of women with abnormal cervical smears of any grade receiving colposcopy appointments within 8 weeks of referral (96.9%) achieved the minimum requirements (≥ 90%). However, the waiting times for women with high‐grade squamous intraepithelial lesion, glandular cell abnormality and invasive lesion smears were longer than recommended by NHSCSP guidelines. The default rate of 15.8% in this study was slightly higher than recommended by the guidelines (< 15%). Having no health insurance, being known to have HIV infection and waiting times longer than 4 weeks were independent predictors of default from an initial colposcopy appointment. Conclusion: The waiting times for colposcopy among women with high‐grade smear abnormality and the default rate failed to meet standard requirements. Designing an effective protocol for colposcopy appointment processes is warranted.     

Cervical cancer screening programs: summary of the 1982. Canadian task force report.

The Canadian Task Force on Cervical Cancer Screening Programs, which produced its first report in 1976, was reconvened by the Department of National Health and Welfare in 1980 in response to concerns expressed about the significance of new data, changing sociosexual patterns and wide variations in the implementation of the 1976 recommendations. This article is a summary of the 1982 task force report. In addition to updates of the 1976 material new sections appear on groups at risk, mathematical models of screening, quality control in screening programs, cytologic screening coverage of the Canadian population and management of patients with abnormal smears. The 1982 recommendations deal with frequency of screening, laboratory quality control and follow-up mechanisms. The task force concludes that measures to improve the quality and sensitivity of screening programs and to include women who have never been screened will be more effective in reducing mortality from carcinoma of the cervix than will attempts to increase the frequency of screening. The task force views as unnecessary the annual screening of women over 35 years of age whose previous smears have been normal. Since younger women are sexually more active and tend to have more than one sexual partner they are at high risk. Therefore, the task force recommends annual screening for sexually active women aged 18 to 35 years. Physicians, health care professionals and government health agencies have a role to play in informing women about the recommended intervals for cervical smears and ensuring that screening programs of adequate quality are available. Although women are primarily responsible for entering and continuing in such a program, government-sponsored registries are essential if the full potential of cervical smear programs is to be realized.     

Oral health-related well-being of the long-term hospitalised elderly

Objective: To investigate oral health‐related well‐being of the long‐term hospitalised elderly as reported by their primary nurses in relation to subject's oral health assessed either by primary nurses or by a clinical dental examination. Background data: Little is known about oral health‐related well‐being of the medically compromised, long‐term hospitalised elderly, most of whom are unable to express their feelings and opinions. Materials and methods: A cross‐sectional study using a questionnaire for primary nurses about oral health and oral health‐related well‐being regarding functional, pain/discomfort‐related, and psychosocial limitations of the subjects (n = 255) and assessment of oral health by clinical examination. The total number of limitations and the number of limitations in each category was calculated. Results: Most (77%) of our subjects were unable to eat normal food. Functional limitations dominated followed by psychosocial and pain/discomfort‐related limitations. Overall assessment by each subject's primary nurse ranked oral health of as good for 9% of subjects, as moderate for 44%, and as poor for 47%. Clinical examination‐based assessment ranked oral health as good for 19%, as moderate for 33%, and as poor for 48% of our subjects, with good oral health being ranked as good for more men than women (26% vs. 16%; p = 0.045). Fewer limitations were recorded for those with better oral health assessed both by primary nurse and by clinical examination. Conclusion: More efforts are called for to maintain the oral health of the long‐term hospitalised elderly so as to improve their well‐being.     

Evaluation of clinical practice guidelines.

Compared with the current focus on the development of clinical practice guidelines the effort devoted to their evaluation is meagre. Yet the ultimate success of guidelines depends on routine evaluation. Three types of evaluation are identified: evaluation of guidelines under development and before dissemination and implementation, evaluation of health care programs in which guidelines play a central role, and scientific evaluation, through studies that provide the scientific knowledge base for further evolution of guidelines. Identification of evaluation and program goals, evaluation design and a framework for evaluation planning are discussed.