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Guidelines for Clinical Practice: From Development to Use
The committee used as a starting point the 1990 IOM report, Clinical Practice Guidelines: Directions for a New Program. That report advised the Agency for Health Care Policy and Research (AHCPR) and its Forum for Quality and Effectiveness in Health Care on their responsibilities for guidelines.
Guidelines for clinical practice cannot realistically be viewed as the solution to the country's health care problems, in particular, the problem of escalating costs. Nevertheless, systematically developed, science-based guidelines can become part of the fabric of health care in this country, and they can serve as useful tools for many desirable changes. Their potential reach extends from improving the quality of clinical care (and its measurement) to helping reduce the financial costs of inappropriate, unnecessary, or dangerous care. Practice guidelines are among the building blocks for informed patient decision making and rational social judgments about what care should be covered by public and private health benefit plans.
As tools and building blocks for positive change, guidelines need to be understood and encouraged in context. That context includes powerful economic interests; changing and sometimes conflicting attitudes about professional and patient autonomy; policy making and implementing institutions that are intensely stressed and sometimes incapacitated; and scientific research that simultaneously expands both knowledge and uncertainty. Above all, the context includes the complex, intimate relationship between individual patients and practitioners who are trying to protect health, manage illness, and preserve dignity under conditions that range from routine to desperate.
WHAT ARE PRACTICE GUIDELINES?
As defined in the IOM's 1990 report, practice guidelines are ''systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." Medical review criteria, which are also discussed in this report, are "systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services, and outcomes."
Practice guidelines focus, in the first instance, on assisting patients and practitioners in making decisions, but this defining characteristic does not and should not preclude their use for other purposes including quality improvement and payment policy making. Conversely, medical review criteria and related tools emphasize the evaluation of health care decisions, actions, and outcomes, but they should and do build on guidelines and may in some cases be virtually identical.
Practice guidelines are not synonymous with the reimbursement or coverage policies of Medicare and other health insurance plans, which traditionally have excluded some items from coverage (for example, immuniza-