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Setting Priorities for Clinical Practice Guidelines Committee on Methods for Setting Priorities for Guidelines Development Marilyn I. Fielct, Editor Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C., 1995

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COMMITTEE ON METHODS FOR SETTING PRIORITIES FOR GUIDELINES DEVELOPMENT JEROME H. GROSSMAN, Chair, Chairman and Chief Executive Officer, The New England Medical Center, Boston, Massachusetts ROBERT A. BERENSON, Co-Founder and Co-Medical Director, National Capital Preferred Provider Organization, Bethesda, Maryland CATHERINE BORBAS, Executive Director, Healthcare Education and Research Foundation, Inc., St. Paul, Minnesota FRANCIS J. CROSSON, Associate Executive Director, The Permanente Group, Oakland, California SHELDON GREENFIELD, Senior Scientist, Primary Care Outcomes, Research Institute, The New England Medical Center, Boston, Massachusetts DAVID H. GUSTAFSON, Professor of Industrial Engineering and Preventive Medicine, Center for Health Systems Research and Analysis, University of Wisconsin, Madison, Wisconsin WILLIAM L. MEDD, Internist, Oxford Hills Internal Medicine Group, Norway, Maine CHRISTINE A. MIASKOWSKI, Associate Professor, School of Nursing, Department of Physiological Nursing, University of California, San Francisco, San Francisco, California WILLIAM L. ROPER,* Senior Vice President and Chief Medical Officer, The Prudential Health Care System, Atlanta, Georgia LOUISE B. RUSSELL,* Research Professor of Economics and Chair of Health Care Policy Division, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey RICHARD N. SHIFFMAN, Assistant Professor of Pediatrics, Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut LINDA JOHNSON WHITE, Director, Department of Scientific Policy, American College of Physicians, Philadelphia, Pennsylvania STUDY STAN Marilyn J. Field, Study Director Kathleen N. Lohr, Director, Division of Health Care Services Nina Spruill, Financial Associate Donna D. Thompson, Administrative Assistant H. Donald Tiller, Administrative Assistant *Member, Institute of Medicine . . . zzz

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Acknowledgments The committee wants to acknowledge those who assisted it in preparing this report. Staff from several organizations informed the committee about their priority-setting processes. They include David Eddy and Margaret Gordon from Kaiser Permanente Southern California, Carolyn DiGuiseppe from the U.S. Preventive Services Task Force, Thomas Holohan from the Office of Health Technology Assessment, Susan Horn from Intermountain Health Care, Gregory Gifford of the State of Minnesota, and John Ferguson at the National Institutes of Health. The authors of three commissioned papers, Susan Horn, Troyen Brennan, and Steven Warunan, helped stimulate discussion at the committee's August workshop, and all the participants in that meeting (see Appendix B) helped the committee develop its thinking. At the Agency for Health Care Policy and Research, David Lanier provided information and documents that increased the committee's understanding of the agency's procedures in selecting topics for guidelines development. Stephen King, the former director of the Office of the Forum on Quality and Effectiveness in Health Care, contributed background information on the organization's early activities. Jarrett Clinton and Clifton Gaus, the former and current directors ofthe agency, encouraged the committee to think broadly about its work. Molla Donaldson, who directed a 1992 Institute of Medicine study on priority setting for technology assessment, provided valuable insights into the analyses and recommendations from that study. During the summer of 1994, Jane Deng, an American Medical Student Association intern, helped in myriad ways including developing legislative and regulatory histories. The successful completion of the study also reflects the contributions of Kathleen Lohr, Claudia Carl, Nina Spruill, Michael Edington, and Donna Thompson. v

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Contents SCARY 1 INTRODUCTION Background, 13 Committee Approach, 15 Priority Setting in Other Organizations, 19 Overview of Report, 25 CRITERIA FOR TOPIC SELECTION Current Criteria for Guidelines Topics, 27 Current Criteria for Technology Assessment, 30 Differences in Criteria for Guidelines and Technology Assessment, 31 Toward Common Criteria?, 32 Additional Criteria, 36 The Relative Importance of Individual Criteria, 37 Procedures for Applying Criteria, 38 Reassessment of Existing Guidelines, 41 3 PROCEDURES FOR PRIORITY SETTING Forum and OHTA Priority-Setting Procedures, 46 Toward Common Procedures?, 50 Process Modifications: Improving the Use of Expert Judgment, 51 Development of a Procedure Manual, 56 . V11 11 27 45

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viii CONTENTS 4 FUTURE DIRECTIONS FOR PRIORITY SETTING Review of Findings and Recommendations on Priority Setting, 57 Definition of Guidelines Topics, 61 National and Local Guidelines, 63 Future Roles for AHCPR, 64 Conclusion, 70 REFERENCES APPENDIXES 57 73 A Setting Priorities for Health Technology Assessment: A Model Process, Executive Summary, 77 B Workshop on Setting Priorities for Practice Guidelines, 93 C Methods for Setting Priorities for Guidelines Development: Medical Malpractice, 99 Troyen A. Brennan D National Guidelines and Local Action: Priority-Setting for the Development of Research-Based Protocols at Intermountain Health Care, 111 Susan D. Horn E The Development of Clinical Guidelines for Primary Care Practice: A Systems Approach, 133 Steven A. Wartman F Examples of Questionnaires for Use in Priority Setting, 151 G Committee Biographies, 157 INDEX Tables 1.1 2.2 2.3 TABLES AND FIGURES AHCPR Guidelines Published and Under Development as of November 1,1994, 15 Legislative Criteria for Selection of Guidelines Topics for AHCPR's Fonda on Quality and Effectiveness in Health Care, from P.L. 102 239 (1989) and P.L. 102-410 (1992), 28 Priority-setting Criteria Specified by the Forum, 29 Criteria for Setting Priorities for Selecting OHTA Technology Assessment Topics, 31

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