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INTRODUCTION AND BACKGROUND 31 not. Some guidelines undoubtedly will save money by reducing the use of inappropriate services; some will increase costs by encouraging more use of underutilized services; and some will shift costs from one service, place, or payer to another. The net impact on costs cannot be predicted with confidence, even if the priorities for guidelines development focus on clinical conditions for which overuse of expensive services is suspected. One of the main areas of disagreement among committee members involved precisely how costs should be considered in the development of practice guidelines. Some committee members believed that all guidelines should incorporate judgments about cost-effectiveness whereas the majority called for the development process, at a minimum, to include projections of cost effects. In any case, if guidelines do succeed in improving the value of the nation's expenditures of medical care by allowing more informed individual and social decisionmaking that in turn shifts expenditures from less to more appropriate forms of care, then the endeavor will be successful. As stated at the outset of this chapter, the committee believes that AHCPR has the potential to strengthen the knowledge base for health care decisionmaking and contribute to the development of practice guidelines. It can be an important element in the much broader array of public and private actions to improve the quality and effectiveness of health care. This report suggests some ways in which the agencyâ with the help of many others and a stance of constructive realismâcan move to meet its mandate. REFERENCES Audet, A., and Greenfield, S. A Survey of Current Activities in Practice Guideline Development. Paper prepared for an IOM Meeting on Medical Practice Guidelines: Looking Ahead, November 8, 1989, Washington, D.C. Brook, R. Practice Guidelines and Practicing Medicine. Are They Compatible? Journal of the American Medical Association 262:3027-3030, 1989. Eddy, D. Clinical Policies. Pp. 47-54 in Proceedings. Standards of Quality in Patient Care: The Importance and Risks of Standard Setting . Invitational Conference, Council of Medical Specialty Societies, Washington, D.C., September 1987. Eddy, D. Methods for Designing Guidelines. Paper prepared for the Physician Payment Review Commission. Duke University, Durham, N.C., 1988. Eddy, D. Comparing Benefits and Harms: The Balance Sheet. Journal of the American Medical Association 263-2493-2505, 1990a. Eddy, D. Guidelines for Policy Statements: The Explicit Approach. Journal of the American Medical Association 263:2239-2240, 1990b. Eddy, D. Practice Policies--Guidelines for Methods. Journal of the American Medical Association 263:1839-1841, 1990c. Eddy, D. Practice Policies--What are They? Journal of the American Medical Association 263:877-880, 1990d. Eddy, D. Practice Policies--Where Do They Come From? Journal of the American Medical Association 263:1265-1275, 1990e. Eddy, D. Designing a Practice Policy: Standards, Guidelines, and Options. Journal of the American Medical Association, forthcoming (a).
INTRODUCTION AND BACKGROUND 32 Eddy, D. A Manual for Assessing Health Practices and Designing Practice Policies (draft dated May 31, 1989). American College of Physicians, forthcoming (b). Field, M. Health Policy and Medical Practice Guidelines: The Case of Mammography Screening for Women Under 50. Paper prepared for an IOM Meeting on Medical Practice Guidelines: Looking Ahead, November 8, 1989, Washington, D.C. Institute of Medicine. Controlling Costs and Changing Patient Care? The Role of Utilization Management, B. Gray and M. Field, eds. Washington, D.C.: National Academy Press, 1989. Institute of Medicine. Medicare: A Strategy for Quality Assurance, vols. 1 and 2, K. Lohr, ed. Washington, D.C.: National Academy Press, 1990. Leape, L. Unnecessary Surgery. Health Services Research 24:352-407, 1989. Leape, L. Practice Guidelines and Standards: An Overview. Quality Review Bulletin 16:42-49, 1990. Physician Payment Review Commission. Annual Report to Congress. Washington, D.C., 1988a. Physician Payment Review Commission. Improving the Quality of Care: Clinical Research and Practice Guidelines. Appendix I. Background Paper for the Conference on Practice Guidelines, Washington, D.C., October 1988b. Physician Payment Review Commission. Annual Report to Congress. Washington, D.C., 1989. Physician Payment Review Commission. Annual Report to Congress. Washington, D.C., 1990. Roper, W., Winkenwerder, W., Hackbarth, G., et al. Effectiveness in Health Care. An Initiative to Evaluate and Improve Medical Practice. New England Journal of Medicine 319:1197-1202, 1988. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions . Baltimore, Md.: Williams & Wilkins, 1989.