Index

A.

Agency for Health Care Policy and Research budget. 56-57, 63

dissemination of guidelines, 190-191

education and dissemination strategies, 88

Forum for Quality and Effectiveness in Health Care, 46, 55, 56, 165 , 212

lessons learned in guidelines development, 165-166

medical review criteria development, 109

Medical Treatment Effectiveness Program, 56-57

Patient Outcomes Research Teams, 56-57, 179

responsibilities for guidelines, 2, 6, 55-57

review of guidelines, 172, 212

topic selection, 175

American Academy of Family Practice, 56

American Academy of Ophthalmology, 48, 169-170

American Academy of Pediatrics, 48, 56, 80, 188

American Board of Family Practice, 87, 101

American Board of Internal Medicine, 87

American Cancer Society, 87, 184

American College of Cardiology, 48-49, 170, 188, 288

American College of Emergency Physicians, 270

American College of Nuclear Physicians, 49

American College of Obstetricians and Gynecologists, 48, 49, 87

American College of Physicians, 184, 188, 275

Center for Applied Research, 52

Clinical Efficacy Assessment Project, 48, 52, 154 n.10, 166-167. 169

American College of Preventive Medicine, 51

American College of Radiology, 48, 49

American College of Surgeons, 264

American Dental Association. 47, 50

American Diabetes Association, 169-170

American Heart Association, 48-49, 170, 288

American Hospital Association, 102

American Medical Association assessment of guidelines, 213

Council on Scientific Affairs, 49

Diagnostic and Therapeutic Technology

Assessment program, 49

''Do Not Resuscitate" guidelines, 28

listings of guidelines, 189

practice guidelines development, 49, 51, 60, 169

Practice Parameters Forum, 49, 60, 169

Specialty Society Partnership, 49, 60, 169

American Medical Center Consortium, 60

American Medical Peer Review Association, 108



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Guidelines for Clinical Practice: From Development to Use Index A. Agency for Health Care Policy and Research budget. 56-57, 63 dissemination of guidelines, 190-191 education and dissemination strategies, 88 Forum for Quality and Effectiveness in Health Care, 46, 55, 56, 165 , 212 lessons learned in guidelines development, 165-166 medical review criteria development, 109 Medical Treatment Effectiveness Program, 56-57 Patient Outcomes Research Teams, 56-57, 179 responsibilities for guidelines, 2, 6, 55-57 review of guidelines, 172, 212 topic selection, 175 American Academy of Family Practice, 56 American Academy of Ophthalmology, 48, 169-170 American Academy of Pediatrics, 48, 56, 80, 188 American Board of Family Practice, 87, 101 American Board of Internal Medicine, 87 American Cancer Society, 87, 184 American College of Cardiology, 48-49, 170, 188, 288 American College of Emergency Physicians, 270 American College of Nuclear Physicians, 49 American College of Obstetricians and Gynecologists, 48, 49, 87 American College of Physicians, 184, 188, 275 Center for Applied Research, 52 Clinical Efficacy Assessment Project, 48, 52, 154 n.10, 166-167. 169 American College of Preventive Medicine, 51 American College of Radiology, 48, 49 American College of Surgeons, 264 American Dental Association. 47, 50 American Diabetes Association, 169-170 American Heart Association, 48-49, 170, 288 American Hospital Association, 102 American Medical Association assessment of guidelines, 213 Council on Scientific Affairs, 49 Diagnostic and Therapeutic Technology Assessment program, 49 ''Do Not Resuscitate" guidelines, 28 listings of guidelines, 189 practice guidelines development, 49, 51, 60, 169 Practice Parameters Forum, 49, 60, 169 Specialty Society Partnership, 49, 60, 169 American Medical Center Consortium, 60 American Medical Peer Review Association, 108

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Guidelines for Clinical Practice: From Development to Use American Medical Record Association, 102 n.2 American Medical Review Research Center, 55, 109 American Nurses Association, 47, 50 American Society for Testing and Materials, 92, 311 American Society of Anesthesiology, 48, 49, 51, 74 American Society of Internal Medicine, 172 Anesthesiology guidelines, 48, 49, 51, 74, 125, 130, 131 Appropriateness of care, 5, 27 cost-effectiveness considerations, 143-144 definition, 28, 33, 154, 155 distinguished from practice guidelines, 60 instruments for determining, 57 as practice policies, 33 precertification of services, 41 purpose of, 60 RAND Corporation criteria, 36, 60 research findings on, 37 Assessment instrument, 19, 173, 209-210 attributes of practice guidelines, 350, 364-404 background, 362-364 clarity, 394-397 clinical applicability, 365-367 clinical flexibility, 368-371 development process, 348-350 ideal, 355-356 multi-disciplinary process, 400-404 pretesting and experience with, 359 purposes of, 347-348 question and response categories, 351-353 reliability/reproducibility, 372-374 response aggregation and display, 354 response scoring, 353-354 scheduled review, 398-399 summary evaluation sheet, 405-410 supporting material for guidelines, 357-358 users, 356 validity, 375-393 Assessment of practice guidelines, 199 AMA attributes for, 49 benefits of, 208-209 clinical trials, 192, 217 computer applications in, 90 cost considerations in, 62 credibility, 215 draft reviewers, 171-173, 193-194, 213 feasibility of, 211-215 focus groups, 167, 192 funding, 20, 214-215 IMCARE Guidelines Network, 172-173 and legal weight of guidelines, 133 organization for, 19-20, 210-215 peer review, 172 program components, 18 publication for, 20, 213-214 surveys, 192 training in, 86 Attributes of practice guidelines, 7, 8, 28-30 medical review criteria, 7, 8, 9, 111-112 B Benefit coverage basic benefits, 13, 154, 156 decision making aid, 169 descriptions, 115, 156 disclosure requirements, 150 exclusions/restrictions, 27, 114-115, 150, 151, 154-155, 156 implementation of practice guidelines, 5, 16, 22, 27, 41, 61, 70-71, 79, 113-119 and liability, 114 n.8, 132 n.23 medical review criteria and, 115-116 patient preferences and, 158 priority setting, 158-159 reforms related to, 22 types of decisions, 114-115 Benign prostatic hypertrophy, 55, 109, 179, 181 Blood transfusions, 34, 73, 158, 306 Blue Cross and Blue Shield Association, 60-61, 113, 154, 156, 169 Board certification, 86-87 Breast cancer, 59, 140, 181, 182 n.8, 184 Brigham and Women's Hospital, 93 C Canada, College of Family Physicians, 101 Canadian Task Force, 173-174, 178 Cardiac technologies, 108, 170 Cardiovascular care, 48, 54, 56, 60 Carotid endarterectomy, 60, 108, 280 Cataract surgery, 60, 108 Center for Health Economics Research, 56 Centers for Disease Control, 54-55, 260 Chest pain management, 170, 270 Children's Hospital (Pittsburgh), 56 Cholesterol screening, 35, 54, 59

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Guidelines for Clinical Practice: From Development to Use Clinical practice guidelines applications, 2, 8, 14-18, 23, 30, 40 , 196-197 see also Implementation of practice guidelines appropriateness criteria distinguished from, 60 as benchmarks for performance, 15, 73, 96, 110 clarity of, 8, 30, 394-397 and clinical flexibility, 8, 30, 368-371 clinically oriented, 36 complexity, 36 content, 29, 32, 74-75, 104 context for understanding, 2, 24 and cost containment, 2, 3-4, 21, 23, 36-37, 99; see also Cost management credibility of, 5, 11, 45, 198 defined, 2-3, 26-27 distinguished from reimbursement or coverage policies, 2-3 educational opportunities in, 10 evaluation of impact of, 6 expectations about, 4, 23, 24, 38-39, 42-43 fears about misuse of, 23-24 funding for, 5 and health care reform, 21-22 and informed patient decision making, 2, 32 legal implications, 49-50; see also Medical malpractice limitations of current efforts, 6, 10, 42, 199 policy makers' interests in, 3-4, 5, 23, 27, 36-39, 198 presentation of, 10 and quality of care, 23, 99 reliability/reproducibility, 8, 30, 372-374 research needs, 24, 174-183 scheduled review, 398-399 statutory recognition of, 17-18, 207 strengths of current efforts, 5-6, 198 study committee membership and activities, 25-26 study objectives, 1-2, 25-26 translation into medical review criteria, 6, 40, 56, 107 types of, 36 users, 3, 36, 38, 40-41 validity, 8, 29, 30, 375-393 variations in, 243-244 see also Development of practice guidelines Clinical trials of clinical alert/reminder system, 91 weight of scientific evidence from, 178 Common Diagnostic Tests,143, 169, 275 Common Screening Tests,143, 169 Computers/computerization, 24 access to information, 93, 94 advances in, 92-93 and application of guidelines, 18 ARDEN syntax, 92-93 assessment of guidelines, 90 CD-ROM disks, 94 n.4 clinical reminders and alerts, 73, 90-91, 95 compatibility/linkages between systems, 9, 92-93, 94, 97 constraints on, 91-92 costs, 92 current systems, 90-92 data collection and analysis strategies, 93 decision support, 93, 94-95 and development of guidelines, 93-94 directions for, 96-98 dissemination of guidelines, 90, 188-190, 208 educational applications, 89 impacts of, 91 information systems, 90-94, 96-98 integrated data bases, 73, 95-96 interactive videos, 89, 181, 194 Medical Logic Module, 311 medical records, 73, 90, 92, 95, 97, 140 medical review criteria algorithms, 109-110 National Library of Medicine, 18, 94, 96-97, 165, 188, 189, 191, 208 outcomes data, 95 quality improvement programs, 72-74, 102 n.2, 140 review and revision of guidelines, 95, 95 self-teaching modules, 88 translation of guidelines for use on, 92-93, 97, 182, 208 Uniform Clinical Data Set, 58 user-friendliness, 80-81, 92, 207-208 voice recognition systems, 81, 93, 97 Conflicting guidelines, 35, 183-184 Congestive heart failure, 56, 166 Continuous quality improvement, 5 administrative focus of, 104-105

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Guidelines for Clinical Practice: From Development to Use deficiencies in, 111 feedback to physicians, 103, 105 by hospitals, 102 implementation of medical review criteria in, 107 implementation of practice guidelines in, 2, 15, 62, 70-74, 103-104, 205-206 JCAHO implementation of, 102 liability problems, 134 as a management strategy, 72-74 models, 102-103, 205-206 principles, 103, 105-106 testing and modification of guidelines, 10, 24 Coronary artery bypass surgery, 49, 60, 105, 170, 323 Cost management benefit coverage determinations. 5, 16, 70, 113-119 consumer incentives, 122 credentialing and selection of practitioners, 16, 119-121 development of guidelines, 7, 12-13, 21-22, 32, 52, 80, 140-146 economic incentives, 16, 121-122 implementation of practice guidelines for, 2, 3-4, 16-17, 21, 36-37, 38-39, 41, 42, 70-71, 135, 140-146, 206-207 incentives for economy and efficiency, 39, 121-122, 123 integrated financial and clinical management computer systems, 95-96 medical review criteria and, 115-116, 206 prior review and, 115-116 proposed directions for, 123 tort liability concerns, 116-119 utilization review and, 116 Costs of health care defensive medicine, 125 n.17 and health benefits, 3, 37 implications included in guidelines, 12-13, 21-22, 135-136, 140-146 and minimum levels of care, 12-13 Council of Medical Specialty Societies, 49, 168 Coverage, see Benefit coverage Critical pathways, 75, 105, 186-187 D Decision modeling, 48 Definitions and terminology appropriateness of care, 28. 33, 154, 155 "basic benefits,"; 13, 154-157 clinical practice guidelines, 2-3, 26-27 concerns about, 155-156 "guidelines,"; 33 "indicated,"; 154 "medical necessity,"; 13, 154-155, 160 medical review criteria, 2, 27 "minimum care,"; 12-13, 154, 157-159 "necessary,"; 154-157 "options for care,"; 33 "standards for care,"; 33, 127, 133 "strong evidence,"; 33 Development of practice guidelines algorithms, 61-62, 181 analytic strategy, 29, 31-32 appropriateness criteria converted into, 60 assumptions about, 4, 38 attributes of guidelines considered in, 29, 49, 111, 116 benefit-harm determinations of alternative courses of care, 31 building a compelling case for recommendations, 7-10, 200 chairperson, 165 clinician participation in, 15 computer applications for, 93-94 consensus approaches, 33-34, 54, 60, 61, 63, 164, 166-168, 176 cooperative actions in, 48-49, 60-61, 168-170 cost-effectiveness considerations, 7, 12-13, 21-22, 32, 52, 80, 140-146 costs of, 62-63, 165, 181, 199, 203-204 desirable attributes of, 7, 8, 28-30 dissemination concerns, 168 n.3 documentation of, 8, 30, 45, 47 n.2, 90, 132, 136, 144, 168 n.3 evidentiary foundation, 4, 7, 24, 29, 31, 32-35, 38, 45, 104, 126, 132, 136, 145, 164, 168 n.3, 178-179 funding for, 5, 56, 60, 61 and implementation of guidelines, 7, 11-12, 45-46, 163-164, 183-192, 201-203 improvements in, 6-14, 199-204 inconsistency and confusion in, 11, 13, 26-27, 28, 35, 76-77, 181-183, 202 see also Definitions and terminology liability considerations, 116-117, 118-119 literature searches, 54, 139, 165, 178 minimum levels of care, 12-13, 153-154, 157-160. 203-204

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Guidelines for Clinical Practice: From Development to Use multidisciplinary process, 9, 30, 45, 167 organizational processes, 164-170, 176-178 and outcomes research, 7, 167 panel creation and member selection, 170-171, 176-178 patient preferences considered in, 31, 68-69. 148-150, 151, 167, 180-181, 199 payer interest in, 112-113 pluralism and diversity in, 5, 6, 42, 46-47, 181-182, 198, 199 priority setting in, 57, 104, 175-176 by private-sector organizations, 59-62 by professional organizations, 1, 5, 46-52 by public agencies, 52-59; see also individual agencies quality control in, 6, 16, 199 quantitative/modeling approach, 176 and research targeting, 35 resources for, 6 revision/updating, 8, 30, 32, 35, 38, 45, 90, 95, 168 n.3, 173-174 substantive content, 7, 8, 32 "sunset" provisions, 173 terminology, 13, 26-27, 28 testing and modification, 10, 20; see also Assessment of practice guidelines time commitment, 165 training for, 168 volume of efforts, 39, 42, 163-164 see also Formats of guidelines: Local adaptation of guidelines; Methodological issues Diabetic retinopathy, 169-170 Dietary cholesterol recommendations, 32 Dysuria, 333 E Education computer applications in, 88, 89 conferences for guideline users, 16, 110-111 evaluation of programs, 109 impact and cost-effectiveness, 88-89 implementation of practice guidelines in, 67, 72-74, 78, 86-90 informal processes, 89 interactive videos, 89, 181, 194 on needs of patients, 89 operations-level feedback, 88, 110 opportunities in development of practice guidelines, 10 outreach programs, 55 patient, 41, 87, 89, 147 personal, interactive strategies, 88 of practitioners, 16, 88, 109, 110, 123 reimbursement for, 89 small-group strategy, 88 training in assessment of guidelines. 84 training of guidelines developers, 168 Emergency room care, 125, 130, 131, 170, 270 End-stage renal disease. 31 n.6 Erythrocyte sedimentation rate tests in diagnosis, 275 Ethical concerns cost-effectiveness considerations, 145-146 information provision to patients, 150-153 informed consent, 138. 147-148 and minimum care and basic benefits, 154-160 obligations of collective social systems. 138-140 obligations of individuals, 136-138 paternalism, 137-138 patient autonomy, 137, 148, 149 patients in persistent vegetative states, 149 terminally ill patients, 138, 149 F Food and Drug Administration, 53 Formats of guidelines, 167 algorithms, 247-248, 270, 333 computer-based, 73, 189, 251, 296, 311, 317 critical pathways, 323 defined, 36 and dissemination, 12, 188-189, 202-203 formalized presentations, 246-251 flowcharts and similar styles, 248-249, 264, 311, 317, 321 free text, 245-246, 252, 260, 264, 270, 275, 280, 288, 296, 306, 328, 336 standards proposed, 249-251 G Group Health Cooperative of Puget Sound, 139-140, 186 H Harvard Community Health Plan Clinical Guidelines Program, 61-62, 333 computer link to Brigham and Women's Hospital, 93

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Guidelines for Clinical Practice: From Development to Use Health care institutional implementation of guidelines, 67, 74-76 minimum levels of, 12-13, 139 rationing of, 139 reforms, 21-22, 135, 156-157, 217-219 "two-tier,"; 160 Health Care Financing Administration, 57-58, 60, 108, 179 n.5 Health examinations, periodic, 59 Health insurance competition and consumer choice among plans, 22, 131-132 deductibles and cost sharing, 121 practice guidelines as mechanism for defining, 5 right to information on treatment options, 150-151 see also Benefit coverage Health maintenance organizations, practice guidelines, 61-62, 67, 113 Health status assessment, 179-180 Holston Valley Hospital, 323 Hospitals clinical pathways or protocols, 105 continuous quality improvement by, 102, 105 implementation of practice guidelines, 74-75, 78, 79 retrospective utilization review programs, 115 Human immunodeficiency virus, universal precautions, 27-28 Hypertension screening, 31 n.6, 54 Hypertension treatment program, 89 I Immunization practices, 54, 55, 59, 151, 182 n.8, 260 Implementation of practice guidelines, 25 by academic medical center hospital, 72-74, 78 in ambulatory care, 62, 68 and behavioral change, 14, 72-74 case studies, 67-77 in certification and re-certification of physicians, 86-87, 101 challenges to, 65-77 clinical research role, 84 by community hospitals, 74-75, 78, 79 conditions for success in, 14-18, 84-85 context considerations, 84 continuous quality improvement applied to, 104 in cost management, 16-17, 27, 36-37, 38-39, 41, 70-71, 99-100, 112-123, 135, 206-207 in credentialing of practitioners, 119-120 dissemination strategies, 12, 54, 87, 94, 170, 188-192, 203 economic factors, 72-75, 79 educational conferences for users, 16, 110-111 for educational purposes, 41, 72-74, 78, 86-90 environmental factors in, 79 format and specificity and, 68-69 "hassle" factor, 68-69, 116 and human errors, 76-77 information and decision support systems, 18, 68-69, 72-74, 80-81, 207-208 institutional factors in, 78-79 interface between development and, 11-12, 45-46, 78, 163-164, 201-203 in internal medicine practice. 68-69 by managed care organization, 70-71, 79 in management decision making and follow-through, 74-75 medical liability and, 41, 51, 67, 74-75, 125-132, 207-208 by nurses and nurse-practitioners, 40 by nursing homes and hospices, 75-76, 78, 79 patient needs, characteristics, and preferences and, 68-69, 74-75, 78, 79, 145 by patients, 39, 40, 76-77, 78, 87, 89 by physicians/practitioners, 23, 40, 41, 66, 67, 78, 153-154 practice variation and, 72-74 for preventive services, 139-140 in quality assurance and improvement, 2, 15-16, 27, 37, 41, 72-74, 205-206 regulation and interpretation of guidelines, 75-76 requirements for. 42 in risk management, 17-18, 37, 41, 51, 74-75, 100, 207-208 strategies to encourage, 79-81, 87 tasks, 65 time constraints, 68-69 training programs, 110 Incentives, economic, 72-75

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Guidelines for Clinical Practice: From Development to Use Inconsistent guidelines, 35, 183-184 Independent practice associations, 67, 121 Information systems, see Computers/ computerization Informed consent, 15, 103 British standard, 147 n.6, 151 n.8 defined, 147 ethical concerns, 138 guidelines for, 28, 152-153 and patient preferences, 147, 151-152 and risk management, 147 Informed patient decision making, 2, 5 as a goal of practice guidelines, 15, 23, 32, 41, 103, 125 guidelines for, 13-14, 28, 152-153, 204 and informed consent, 148 patient preferences and, 145, 148-150 responsibilities for provision of information, 151-152 risk management and, 125 Intermountain Health Systems (Salt Lake City), 96 Internal Medicine Center to Advance Research and Education, 172-173 Internal medicine practice, 68-69, 78 International Society for Technology Assessment in Health Care, 168 n.3 Interstudy, Outcomes Management System, 120-121, 179 n.5 J John A. Hartford Foundation, 60, 166, 168 Johns Hopkins University Program for Medical Technology and Practice Assessment , 86 Joint Commission on Accreditation of Health care Organizations, 28 , 71, 102 K Kaiser Permanente, 62 L Labor and delivery after previous cesarean section, 296 Latter Day Saints Hospital (Salt Lake City), 91 Litigation benefit coverage, 114 n.8 Helling v. Carey,128 n.21 medical liability, 114 n.9, 117 Pirozzi v. Blue Cross and Blue Shield of Virginia,114 n.8, 117 n.11 Rollo v. Blue Cross-Blue Shield of New Jersey,117 n.11 Salgo v. Leland Stanford Junior University Board of Trustees,147 Wickline v. California,114 n.9, 117, 118 Wilson v. Blue Cross of California,114 n.9, 118 Local adaptation of guidelines case studies, 70, 72-74, 75-76 and conflict and inconsistency, 183-184 evidentiary foundation of guidelines and, 32 processes for, 6, 186-187, 199, 202 reasons for, 11-12, 184-186, 202 and stature of guidelines, 187-188 Low back pain, 181, 321 M Maine, medical liability demonstration project, 130 Managed care organization, 70-71, 79 Maryland Hospital Association, quality indicator project, 102 Massachusetts General Hospital (Boston), 91 Massachusetts, risk management strategy, 131, 270 Mayo Clinic, 60 Medicaid. 113, 117 length-of-stay criteria, 118 Oregon reforms, 157 Medical malpractice continuous quality improvement models and, 134 contract language for HMOs, 132 n.23 cost management and, 17, 114 customary practice, 127 decision making reforms, 22 "defendent use only" aspect of guidelines, 130-131, 133 and defensive medicine, 125 n.17, 126 defined, 127-128 duty of care, 117-118 hearsay evidence, 128 immunity from liability, 17, 117 n.11, 128, 129, 130, 132, 133, 187 , 207 implementation of practice guidelines and, 41, 51, 67, 74-75, 100, 125, 126 informed consent and, 147 insurance premiums, 51, 125, 131 "learned treatises,"; 128 local adaptation of guidelines and, 187-188 negligence standard, 117, 118, 125, 153, 159

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Guidelines for Clinical Practice: From Development to Use physician responsibility for care, 118 reform issues, 126, 131-132 research on. 133 standard-of-care determinations, 127, 128-132 "strict locality rule" and "similar locality rule."; 127 underwriters' development of guidelines, 51 variation in, 58 weight of guidelines in decision making on, 17, 128-132, 207 see also Litigation: Risk management Medical necessity, 13 Medical review criteria appeals criteria, 9, 112 and benefit cost management, 115-116 computerization. 9, 109-110, 112 criticisms of, 17, 58, 69, 107-108, 116, 207 defined, 2, 27 desirable attributes of, 7, 9, 17, 28, 111, 112, 116, 123, 206 development of, 107, 109-110 evaluation of, 109 feasibility, 9, 112 implementation issues. 107-108 obtrusiveness. 9, 112 patient responsiveness to, 9, 112 patterns-of-care focus, 107 private sector implementation, 109-110 public sector implementation of, 108-109 readability, 9, 112 sensitivity of, 9, 112 specificity of, 9, 112 translation of practice guidelines into, 6, 55-56, 107, 199 Medicare, 113 carriers and fiscal intermediaries, 107 controls on payments, 37 defensive medicine costs, 125 n.17 medically necessary care standard, 155, 159 reimbursement policies, 27, 156 Medicare Peer Review Organizations (PROs) criticisms of, 132 defined, 57-58 implementation of practice guidelines, 67 liability of, 129 review criteria, 17, 55, 58, 107-108, 133 utilization review activities, 108 The Merck Manual,62 Metabolic acidosis, 311 Methodological issues, 200-201 algorithmic analysis, 182 analytical strategy for guidelines development, 29, 31-32 committee focus, 10-11, 142 conflicts and inconsistencies in guidelines, 181-183 cost-effectiveness analysis and estimation, 141-142 evaluation of scientific evidence, 178-179 expert panel processes, 176-178 patient preferences incorporated into guidelines, 180-181 problems, 39 research needs, 174-183 topic selection, 175-176 Micromanagement of professional and institutional behavior, 17, 23 , 123 Minimum Care, 154-159 Minnesota Clinical Comparison and Assessment Project, 61 N National Cholesterol Education Program for Adults, 54 National Demonstration Project on Quality Improvement in Health Care , 102 National Heart, Lung, and Blood Institute, 54 National High Blood Pressure Education Program, 54 National Institutes of Health Consensus Development Conference Program , 54, 167-168, 175 Office of Medical Applications in Research, 53-54. 63, 167 National Library of Medicine (NLM), 18, 27, 94, 96-97, 165, 188, 189, 191, 208, 214 New England Medical Center hospitals (Boston), 96, 323 Nursing homes and hospices, 75-76, 78, 79, 138-139 O Obstetrics and gynecology guidelines, 48, 49, 87, 130 Office for Health Services Research Information, 18, 208 Office of Health Technology Assessment, 176

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Guidelines for Clinical Practice: From Development to Use Office of Technology Assessment, 59 Omnibus Budget Reconciliation Act of 1989, 55, 56, 65 n.1, 94, 175 , 179 Oral contraceptives, 317 Oregon Basic Health Services Act, 157 Otitis media in children, 56, 166 Outcomes of care, 5 assessment of, 7, 29, 110 continuous quality improvement and, 104 incorporation in practice guidelines, 179-180 Interstudy Outcomes Management System, 120-121 methodologic concerns, 179-180 patient preferences, 148 in patient satisfaction surveys, 15, 103 practice guidelines and, 15, 95, 100 research on, 5, 37-38, 42, 56-57 uncertainties about, 37-38 P Pain management, 55, 76, 109, 170, 191 n.,11, 270, 336 Patients autonomy, 137, 138, 148-150 economic incentives for cost containment, 16 education, 41, 87, 89, 147 guidelines content for, 32, 252, 260, 296, 306, 321 implementation of practice guidelines, 39, 40, 66, 67, 76-77, 78, 79, 87 information on cost control incentives, 121-122 noncompliance with treatment regimen, 89 preferences, 29, 31, 103, 145, 147, 148-150, 158, 180-181 satisfaction with care, 15, 103 see also Informed patient decision making Peer Review Organizations, see Medicare Peer Review Organizations Pew Memorial Trust, 60 Physician-patient relationship, 89, 138 Physician Payment Review Commission, 49 Physicians availability of computer-based information systems, 93 behavioral change, 72-74, 85, 88 certification and re-certification of, 86-87, 101 feedback to, 70-71, 72-74, 88, 103, 105, 110, 123, 172 implementation of guidelines, 23, 40. 41. 66, 67, 78, 153-154 licensure conditions, 131 practice patterns, 72-74, 85 see also Practitioners Physicians' Desk Reference,62, 69, 76 Poststroke rehabilitation, 56, 166 Practitioners attitudes about prior review programs, 115-116 autonomy concerns, 24, 66 credentialing, 16, 119-120 economic incentives for cost containment, 16 educational strategies for, 88, 109 ethical obligations to patients, 136-137 objections to practice guidelines, 24 performance evaluation, 61 sanctions against, 110, 120 selective contracting, 16, 120-121 self-regulation, 17, 123 variations in practice patterns, 37 Preferred provider organizations, 113, 121 President's Commission for the Study of Ethical Problems in Medicine and Bio- medical and Behavioral Research, 147 Pressure sores, prevention, 75 Preventive interventions, 58-59, 71, 139-140, 158 Prior review programs, 115 Professional organizations development of guidelines. 1, 5, 6, 47-52. 168-170 focus of. 47 interests in practice guidelines, 50-52 journals, 47, 49 see also individual organizations Prospective preprocedure and preadmission criteria, 17. 58, 109, 206 Psoriasis, 328 Public Law 92-703, 129 Q Quality assessment. 5, 41, 107 Quality assurance Appropriateness Evaluation Protocol. 57 benchmarks for performance, 15 chart audits, 101, 105 conceptual framework, 101 educational strategies and, 87 evaluations of performance and outcomes data, 16

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Guidelines for Clinical Practice: From Development to Use feedback to practitioners, 16 implementation of practice guidelines for, 37, 41, 205 proposed directions for, 110-111 revision/updating of guidelines, 16 tests of clinical skills, 101 see also Continuous quality improvement Quality control, in guidelines development, 6 Quality improvement, see Continuous quality improvement; Total quality management Quality of care defined, 100 management commitment to, 103 practice guidelines and, 23, 99, 100 R Radiology guidelines, 48, 49, 130 RAND Corporation, 36, 56, 57. 60, 109, 155, 169, 280 Regenstrief Medical Record System, 90 Reimbursement, 74, 89 Report on Medical Guidelines & Outcomes Research,189 Research agenda adoption and diffusion of medical innovations, 21, 35, 216 assessment instrument, 21 conflicts and inconsistencies in guidelines, 181-183, 216 expert panel processes, 176-178, 216 impact of practice guidelines, 21, 35, 104, 216-217 incorporating outcomes information into guidelines, 179-180 medical liability, 133 methodologies for evaluating scientific evidence, 178-179, 216 on outcomes and effectiveness of health care services. 3, 24, 38, 42, 56-57, 104, 215-216 patient preferences, 180-181 testing effectiveness of practice guidelines, 21, 216 topic selection, 175-176 Retrospective review of care, 17 Risk management computer applications in, 95 educational strategies and, 87 implementation of practice guidelines in, 17-18, 37. 41, 51, 74-75, 100, 124-125 informed consent and, 147 physician conditions of licensure, 131 see also Medical malpractice Robert Wood Johnson Foundation, 60, 102 Scientific American Medicine,62 Selective contracting, 70-71 Society for Medical Decision Making, 50 Society of Nuclear Medicine, 49 Standards for care, 33, 56 Sweden, clinical practice guidelines, 35 T Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures, 48-49 Terminology, see Definitions and terminology Third-party payers implementation of practice guidelines by, 5, 16 , 22, 27, 41 liability for negligence, 117 Total quality management, 102, 104-105 Triage of injured patients, 145, 264 U United Health Care, 62 Universal precautions, 27-28 Urinary incontinence, 55, 109, 333 U.S. Health Care, 62 U.S. Preventive Services Task Force, guidelines, 34, 58-59, 63, 172 , 252 U.S. Public Health Service, guidelines development, 53-57, 143, 172 Utilization review appropriateness criteria, 57 concurrent review of inpatient care, 115, 117 and cost control, 116 criticisms of, 107-108 by hospitals, 115 implementation of practice guidelines, 116, 206-207 liability, 114 n.9, 117-119 medical review criteria in, 107 by PROs, 57-58, 108, 129 retrospective, 115 role of, 17, 70-71, 101, 123, 207 by third-party payers, 115 V Vaccinations for pregnant women, 55, 260 Value Health Sciences, 60 definition of appropriate care, 155 Medical Review System, 109 Visual acuity screening of children, 59, 252 W Wishard Memorial Hospital, 90