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Knowing what Works in Health Care: A Roadmap for the Nation
CRITICAL PROGRAM CHALLENGES AND RECOMMENDATIONS
Building on the Current System
Efforts to improve the quality and availability of clinical practice guidelines need not involve a wholesale restructuring of the current system. The recommendations proposed by the committee build on the aspects of the current system that are functioning well—including the work of the USPSTF, the ACC/AHA, and others—but seek to raise the standards for producers of clinical practice guidelines overall.
Building on the current system is practical for a number of reasons. First, the experience of the AHCPR in the 1990s exposed the significant political risks involved in establishing government-sponsored clinical practice guidelines. When an AHCPR Patient Outcomes Research Team developed a guideline on the treatment of back pain, an angry group of orthopedic surgeons almost succeeded in convincing Congress to defund the agency (Gray, 1992; Gray et al., 2003). In addition, the private organizations that currently produce guidelines, such as professional societies and others, treasure their autonomy and would likely oppose efforts to reduce their role. Furthermore, guidelines that have the imprimatur of a respected professional society engender trust by the end users (Tunis et al., 1994). Finally, there are some indications that the quality of these guidelines has improved over time (Jackson and Feder, 1998), although data need to be updated. For these reasons, the committee believes that the pragmatic approach—and also the most promising approach—is to build on the current system.
Clinical practice guidelines vary widely in their methodological rigor and protection from bias; however, in the current environment, the organizations and individuals who use guidelines have very limited means to assess their objectivity or accuracy. The committee recommends several steps to ensure that the information communicated through practice guidelines is trustworthy.
Recommendation: Groups developing clinical guidelines or recommendations should use the Program’s standards, document their adherenceto the standards, and make this documentation publicly available.
The committee recommends that guideline development organizations adhere to a common set of standards that address the structure, process, reporting, and final product that contains the guidelines. Ensuring adherence to these standards, in part through public disclosure of adherence data,