Background The legislature passed comprehensive health reform legislation in 2009 directing the state to “set standards for safe and effective care”, including development of “best practice guidelines and standards that can be uniformly applied across public and private health care”.

Objectives Develop guideline methodology and guidelines for statewide clinicians and payers.

Methods Employed ADAPTE framework for guideline development. Initial guidelines selected for development included three low back pain (LBP) topics: general evaluation and management of LBP (results described below), advanced imaging for LBP, and percutaneous interventions for LBP. Existing (seed) guidelines identified by searching 17 databases. Quality evaluated using modified AGREE II instrument. Multidisciplinary guideline development group selected and adapted seed guidelines. Stakeholder, peer review and public comments were solicited.

Results Thirteen seed guidelines were identified and 10 met minimal inclusion criteria for LBP evaluation and management topic. Dual quality rating found five of good or fair quality. Final seed guideline selected based on quality and scope. Key recommendations were adopted for state Medicaid programme, including conservative and chiropractic care only in first month and no advanced imaging without clinical “red flags”. A consumer booklet was developed and distributed to consumer, provider, and payer groups. Over 2500 booklets were distributed, with over 11,000 page views on the website. The initial guideline process took over one year to complete.

Discussion Starting a new multi-stakeholder guideline development programme requires substantial investments of methodological expertise, staff time, funds and political capital, but can substantially impact state health policy decisions.