Clinical practice guidelines (CPGs) are systematically created recommendations to assist physicians in the decision making processes related to the choice of health interventions.1 ,2 There has been increasing interest in the development of CPGs within all medical fields. In 1993 there were 374 publications indexed by MEDLINE as pertaining to CPGs; by 1996, the number had increased to over 980. The American Medical Association has listed in their “Directory of Medical Parameters” over 1600 sets of guidelines.3 The enthusiasm and frenzy are such that “Guidelines for the development of guidelines” have been proposed.4 The American College of Rheumatology has also developed several sets of guidelines covering areas such as osteoarthritis, rheumatoid arthritis, and steroid induced osteoporosis.5-11

Variation in practice has been reported for most fields in medicine, including musculoskeletal diseases, often driven by physician preferences or practice characteristics. For instance, prescriptions of second line drugs for patients with rheumatoid arthritis vary among rheumatologists.12 ,13 Demographic characteristics of the prescribing physician seem to have more impact in the selection of specific second line agents than the clinical characteristics of the patient.13 Similar variation has been seen at the primary care level and other specialties for osteoarthritis and low back pain.14-18 In one study where outcomes were reported patients with low back pain treated by “high prescriber” family physicians had the same outcomes as patients treated by “low prescribers”, but much higher medical costs.17 In this age of shrinking budgets and limited resources practice variation may be considered inappropriate not only when resulting in differences in outcomes (benefits or risks) but also when substantial economic costs arise from interventions with unclear advantages.

Where there is no clear evidence favouring the use of one drug over another, practice variation may be readily understandable. …