mittee observed several promising efforts at improving structures and processes for developing guidelines, strengthening methods, and incorporating more attention to implementation, evaluation, and revision.

This last step is critical to effective, comprehensive application of guidelines. The attitudes, needs, and circumstances of practitioners, patients, and other users of clinical practice guidelines must be anticipated and considered from the earliest stages of guidelines development, if guidelines are to be applied to achieve their goals. Likewise, evaluation issues—the intended effects of guidelines, means of measuring impact, potential confounding factors—have to be considered when guidelines are being framed rather than dealt with after the fact.

The next, concluding chapter of the report brings together this committee's principal conclusions and recommendations about the clinical practice guidelines enterprise. It does so in some comfort with the progress that the field has made in recent years, taking it as a good omen of the progress that can be made on the many conceptual, practical, methodological, and political challenges that still remain.

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