The role of clinical practice guidelines has changed dramatically the past 50 years. Both beneficial, as also having some disadvantageous effects. Considering the international developments, such as a growing body of evidence and evolving methodologies, some limits might be in reach or already been reached. The solution thereof is part nationally and part internationally. Internationally because of new methodologies and technologies, such as use of artificial intelligence, and nationally in a more coherent approach. Coherent not only in medical disciplines, but also in policies of government, regulators, and health insurers. This calls for a renewed, integral and an all-encompassing vision.

In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence.
This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis.
Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01).
There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

BACKGROUND: Although patient charges for health-care services may contribute to a more sustainable health-care financing, they often raise public opposition, which impedes their introduction. Thus, a consensus among the main stakeholders on the presence and role of patient charges should be worked out to assure their successful implementation.
OBJECTIVE: To analyse the acceptability of formal patient charges for health-care services in a basic package among different health-care system stakeholders in six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine).
METHODS: Qualitative data were collected in 2009 via focus group discussions and in-depth interviews with health-care consumers, providers, policy makers and insurers. The same participants were asked to fill in a self-administrative questionnaire. Qualitative and quantitative data are analysed separately to outline similarities and differences in the opinions between the stakeholder groups and across countries.
RESULTS: There is a rather weak consensus on patient charges in the countries. Health policy makers and insurers strongly advocate patient charges. Health-care providers overall support charges but their financial profits from the system strongly affects their approval. Consumers are against paying for services, mostly due to poor quality and access to health-care services and inability to pay.
CONCLUSIONS: To build consensus on patient charges, the payment policy should be responsive to consumers\' needs with regard to quality and equity. Transparency and accountability in the health-care system should be improved to enhance public trust and acceptance of patient payments.

BACKGROUND: We wanted to measure adherence to the guideline for depression in disability assessments. The research questions we addressed were: How can we develop performance indicators (PIs) for adherence to the Dutch guideline for disability assessment of patients with depression and how can we measure the quality of the scores? What is the inter-rater reliability of these PIs? What is the quality of the PI scores?
METHODS: PIs, developed by the researchers, were reviewed on various aspects, by a panel of seven experts in several consulting rounds. After adjustments, senior insurance physicians (IPs) attended two training sessions and scored the PIs on 10 different simulated case reports. Two researchers developed proxy \'gold standard\' scores for these 10 case reports. To assess the inter-rater reliability and the quality of the scores, we calculated the intra-class correlations (ICC) and 95% confidence intervals (CI) of the PI scores and of the PI scores compared to the proxy \'gold standard\', respectively.
RESULTS: Six specific and relevant PIs resulted from the consultation of the panel of experts. The PI scores for the 10 case reports, rated by seven (of the eight) senior IPs who completed both training sessions, showed that the PIs were not reliable at individual level (ICC = 0.543; 95% CI 0.426-0.642). However, the ICC became more reliable as an average of two raters was calculated (ICC = 0.704). The ICC of the PI scores with the proxy \'gold standard\' was 0.538 (95% CI 0.419-0.640), but the quality was higher when calculated as an average of two raters (ICC = 0.700).
CONCLUSIONS: The PIs for adherence to the guideline were sufficiently reliable, and the quality of their scores was adequate if at least two well-trained raters were involved. The senior IPs evaluated the feasibility of the PIs as good, with a prerequisite of sufficient training. This method may be interesting for measuring guideline adherence and quality of disability assessments in general.

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Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.

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