" Gastrointestinal endoscopy has achieved a high standard of accuracy and efficacy in the exploration of the lumen of the digestive tract; this explains the widespread diffusion of the procedure and its major role in the detection and management of digestive diseases, both malignant and nonmalignant. However, its benefits must be weighed against: (i) the variable but generally high costs of the procedure; (ii) the potential risk of complications, and (iii) poor acceptance or tolerance by patients. Many studies have been devoted to the cost-effectiveness of endoscopy; they should be preceded however by an evaluation of which indications are appropriate or inappropriate. Appropriate use of endoscopy is to be fostered, thus limiting both over- and underuse of the procedure. Indications should be explored in terms of the outcome after the procedure. Such outcomes will include the detection of disease, impact on treatment and, of course, the physical and psychological wellbeing of the patient. Alternative diagnostic methods should also be concurrently explored, and the necessary nature of a procedure determined when there is a substantial and probable benefit and when no other cost-effective procedure is available. In recent years the Lausanne group has been very active in the evaluation of digestive endoscopy. Its most recent contribution to this field is the organization and conducting of a multicountry and multidisciplinary study, using the RAND methodology for decision analysis. Virtually all situations where gastroscopy or colonoscopy has been proposed were examined in terms of appropriateness. The work conducted by a panel of specialists was supported by an extensive review of literature. The fruits of this considerable amount of work are now published in a special issue of this Journal, with different chapters combining the literature basis and the findings of the panel for major clinical categories. "

" BACKGROUND: Important efforts have been invested in the past few years in the development of quality clinical guidelines. However, the means for the effective dissemination of guidelines to practicing physicians have not been determined. Several studies have examined the possibilities offered by the World Wide Web (the Web), but studies examining the implementation of clinical guidelines in actual practice are clearly lacking. OBJECTIVE: This study assessed the potential of the Web to implement clinical practice guidelines in actual clinical settings. It also documents the obstacles perceived by the physicians in their use of guidelines on the Internet to determine the role that the Web can play in the implementation of guidelines in practice. METHODS: Two guidelines were developed using a standardized panel method and made available via the Web. One concerned indications for low-back surgery and the other dealt with indications for upper and lower digestive endoscopies. To identify obstacles to their use in clinical practice, 20 physicians were asked to consult the guidelines during consultations with patients. Answers were collected using 3 different questionnaires. RESULTS: Questionnaires were completed for consultations involving 213 patients. Less than 50% of the physicians have direct access to the Internet in their examination room. For 75%, the use of the guidelines was easy and the time required to consult them acceptable (3.4 minutes on average, or 12% of the time spent with the patient). The fear that use of such guidelines might interfere with the physician-patient relationship was mentioned as a reason for not consulting the guidelines for 27 consultations. Taking into account their experience with the Web, 75% of the physicians considered that the Web has a great or very-great potential for the dissemination of guidelines and 78% indicated that they would use such guidelines if they became generally available for clinical questions that concerned them. Only 3 physicians had consulted guidelines on the Web prior to this study. CONCLUSIONS: The acceptance of use of clinical practice guidelines via the Web is high. The main limits to further use of such Web-based guidelines seem to be the lack of a computer connection in the physician's office or examining room and the fear that use of such guidelines might interfere with the physician-patient relationship. Though most participants appreciate the considerable potential of the Web for disseminating guidelines, only a small handful regularly use guidelines available on the Web. There are still numerous obstacles to the regular use of guidelines in clinical practice, some related to the physicians, others to the guidelines themselves. "