The intended and unintended consequences of clinical guidelines


  • Financial support for this study was provided entirely by a grant from National Institutes of Health (#R01 DK66425).

Rebecca J. Shackelton
New England Research Institutes
9 Galen Street
MA 02472


Objectives  First, we examine whether clinical guidelines, designed to improve health care and reduce disparities in clinical practice, are achieving their intended consequences. Second, we contemplate potential unintended consequences of clinical guidelines.

Method  As part of a factorial experiment we presented primary care doctors (n = 192) with clinically authentic vignettes of a ‘patient’ with already diagnosed diabetes with an emerging foot neuropathy. Their proposed clinical actions were compared with established practice guidelines for this clinical situation.

Results  After establishing the existence of consistent socioeconomic disparities in the proposed management of the case presented, we found that reported use of practice guidelines had no measurable effect towards their reduction (one intended consequence). However, the reported use of practice guidelines appeared to precipitate more clinical actions, without eliminating documented disparities.

Conclusions  Consistent with other research we find that clinical practice guidelines are not producing a principal intended result, and may even produce unintended consequences.