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4 Future Directions for Priority Setting This chapter summarizes the recommendations presented in the preceding chapters. It also briefly discusses other issues and concerns related to the agency's responsibilities for developing, disseminating, and evaluating clinical practice guidelines. Some points build on the work of earlier Institute of Medicine (IOM) committees, which stressed that planning for successful implementation of guidelines must begin early. Topic selection and definition are critical first steps in looking ahead to the attitudes, needs, and circumstances of those who are the intended audience for practice guidelines. REVIEW OF ENDINGS AND RECOMMENDATIONS ON PRIORITY SETTING The Forum's procedures for priority setting have clearly evolved since its early days when it was operating on a short and unrealistic timetable for developing guidelines. The informal process used by the Forum in selecting its earliest topics was relatively simple but not very explicit or open. Although the committee heard criticisms of the topics initially selected, it was difficult to distinguish criticisms of the topics selected from criticisms of the content or format of guidelines documents or their dissemination and implementation. The Current AHCPR Process and the OHTA Option To recapitulate, the current priority-setting process as described to this committee now includes explicit criteria for topic selection, considerable 57

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58 SEITING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES consultation with outside groups by means of questionnaires and meetings, required solicitation of comments on topics and suggestions for topics through the Federal Register, and a final decision by the administrator with review by the Agency for Health Care Policy and Research (AHCPR) National Advisory Council. The selection criteria have not been defined in explicit, operational terms either for purposes of numerically scoring topics or for more general analytic use. Staff do collect information relevant to potential topics including data on prevalence, cost, and mortality and morbidity, and some of that information is provided to participants involved in discussions oftopic categories. Staff also attempt to determine whether the topic is covered by sound existing guidelines and to estimate the resources required for developing guidelines on a topic. The committee concluded that the Forum's current approach to priority setting is relatively open, fairly explicit, and generally defensible. The efficiency and manageability of the current process are, however, difficult to judge because procedures have not yet been made routine. A more formal alternative, a model process that was recommended by a 1992 IOM committee on priority setting for technology assessment, has been provisionally adopted by AHCPR's Office of Health Technology Assessment (OHTA). This committee concluded that this process provides a clear and reasonable framework for an organization willing and able to commit resources for the required data collection and analytic steps. The committee, however, identified some problems of criterion measurement and application that need attention. As the AHCPR tracks and evaluates the experience of OHTA, it will be able to assess the method's strengths and limitations (e.g., in terms of efficiency, usable results), identify ways of improving it, and decide whether and to what extent the OHIA process should be adopted or modified by the Forum. In the meantime, the Forum should move forward in systematizing and improving its current procedures, as recommended below. Some of these recommendations are also relevant to OHTA. Criteria and Their Application Both the Forum and OHTA have made public the criteria they apply in selecting topics for guidelines development and technology assessment, respectively. Although the criteria now used by the two organizations do not differ radically, the committee concluded that more commonality in criteria, definitions, and measures is desirable. Where the Forum and OHTA differ, the differences should be explained by differences in organizational responsibilities or resources.

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FUTURE DIRECTIONS FOR PRIORITY SETTING 59 The committee recommended that six general criteria be applied in considering topics for either guidelines development or technology assessment. These criteria are prevalence ofthe clinical problem (number of affected persons per 1,000 persons in the general U.S. population); burden of illness imposed by the problem (individual mortality, morbidity, or functional impairment); cost (cost per person of managing the problem); variability in practice (significant differences in utilization rates for prevention, diagnosis, or treatment options); potential of a guideline or assessment to improve health outcomes (expected effect on health outcomes); and potential of guideline or assessment to reduce costs (expected effect on costs to sponsoring organization, other relevant agencies, patients and families, and/or society generally). Because it is likely that data for measuring criteria will often be incomplete, the priority-setting process should provide a clear opportunity for review that allows important unmeasured factors to be considered and measurement biases adjusted, perhaps using expert estimates. The Forum states now that it considers the potential for a guideline to reduce significant clinical variation in the use of services. The committee recommended the emphasis should be on the potential for a set of guidelines to influence behavior in ways that improve patient outcomes or increase efficiency without harming patients. As starting points, this report includes provisional questionnaires for the Forum to consider in assessing this potential. On occasion, however, even if it appears that clinicians or patients may strongly resist change at first, the Forum may reasonably proceed with guidelines when the scientific evidence is clear that an alternative to current practice is preferable. Guidelines may, in such circumstances, be viewed as an initial, educational phase of a long-term effort to change behavior and improve outcomes. The Forum has stated it considers the availability of scientific evidence in selecting guidelines topics. In contrast, the OHTA contends that the availability of evidence should not should not affect whether a topic is chosen for technology assessment but only how it is assessed. Although the committee understands the rationale for this position, it noted that one of the comparative advantages of the AHCPR is that it is better situated to mobilize expertise to analyze scientific evidence than most health care delivery and professional organizations. AHCPR should emphasize the contribution it can malce by providing a strong analysis of the evidence about appropriate care for specific clinical conditions. Thus, the committee agreed that it is reasonable for the Forum to consider the evidence base as one factor in topic selection. Also, some consideration of whether an issue is controversial and whether the controversy is amenable to technical clarification is reasonable. One question that arose in the committee deliberations is whether the Forum should apply additional criteria to ensure (or at least make it likely) that the recommended topic list includes subjects related to specific population subgroups

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60 SETTING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES (e.g., children), to certain broad clinical problems or diseases (e.g., cardiovascular disease), or to particular legal, ethical, or social concerns (e.g., malpractice). The committee concluded that it was acceptable for the agency to establish separate "tracks" for considering such issues. The Forum has essentially done this in the past when it singled out certain clinical areas such as prenatal care and then convened special panels to nominate and rank topics in these areas. In the future, the committee recommended that the Forum should define more clearly its rationales for designating such special topic categories as worthy of such special consideration. The rationales should reflect explicit judgments about how important it is to have the special categories represented in the topic list presented to the AHCPR administrator for final decisions. The rationales can then be critiqued, which may, in turn, suggest alternative emphases that would be more consistent with program and policy objectives. In addition to giving special consideration to certain topic categories, the Forum also must assess whether previously published guidelines need updating. Some updates may involve the correction of errors, refinements in formatting, or other revisions that can be handled primarily by staff without a large investment of Forum resources. The availability of new evidence, however, raises the question of substantive reassessments and their priority. For the foreseeable future, it seems prudent for the Forum both to include existing guideline topics routinely when it solicits comments on proposed topics for guidelines development and to designate a separate "track" for considering these comments, the results of literature searches, the established criteria, and the priority for specific updates. Modifications in Procedures Committee recommendations for improving the Forum's current priority- setting procedures focus on (1) methods for obtaining expert judgment and developing consensus positions and (2) the desirability of a basic procedure manual. Specifically, Forum staff should develop model Delphi or Delphi-like procedures for obtaining expert judgments or topic rankings by mail, fax, or electronic mail; devise questions that are specific, explicit, and consistent with standard protocols for questionnaire construction; and experiment with more formal procedures to arrive at group judgments during the meetings it convenes as part of its current priority-setting activities. The dual objectives of these recommendations are, first, to help participants clarify their thinking and their rationales and, second, to malice more productive use of expert judgment. At certain stages, more coronal consensus development

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FUTURE DIRECTIONS FOR PRIORITY SETTING 61 procedures should also prove useful for the expert panels actually developing practice guidelines. Appendix F includes two provisional questionnaires that the Forum should consider when it next surveys practitioners or others for their views on guidelines priorities. Another improvement the Forum could make in current procedures is development of a basic procedure manual for priority-setting activities. The manual, which could be developed with assistance from health services researchers and methodologists elsewhere in AHCPR, should cover common activities such as questionnaire construction and analysis and consensus development methods. The purposes of such a manual would be to simplify and regularize the priority-setting process and to allow continuing and new staff to work more efficiently. Indeed, the committee recommended that the Forum should extend the manual to cover the guidelines development procedures and methods. Other studies now being sponsored by AHCPR should be useful in this regard (MOGA, 1994a,b). DEFINITION OF GUIDELINES TOPICS During its work, the committee heard repeated concerns that the Forum's priority-setting process needed to define more narrowly and precisely the topics it selected for guidelines development. One complaint was that the panels formed to develop guidelines spent too much time narrowing very broad topics down to a more manageable clinical focus and then had insufficient time for assessing evidence and formulating guidelines in language and formats that target users would find persuasive and useful. It was also suggested that narrower topics should focus on issues most amenable to clarification through authoritative assessment of scientific evidence. Although those responsible for developing guidelines will also need to consider the specific definitions of their topics and the need for adjustments in those definitions, this committee agrees that the Foru~n's priority-setting process should adopt as a new objective the more precise and narrower definition of guidelines topics. For example, if those involved in nominating topics can agree that the major quality, cost, and other concerns about lower back pain involve the management of acute lower back pain and if it appears that reasonable scientific evidence is available for evaluation, then the priority-setting process should identify that target (not back pain generally). In addition, specification of target patient populations and outcomes of primary interest should be part of this early topic definition process. Because the focus of the priority-setting process is specification of topics rather than development of guidelines, it should be relatively straightforward and inexpensive to use mail questionnaires,

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62 SETTING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES structured meetings, staff analyses, and other parts of the process to elicit more specificity in topic definition. Earlier attention to topic definition and a focus on narrower topics should have several positive effects: (1) the composition and work of the development panel can be more efficiently organized from the outset; (2) some apparent controversies may disappear when clinical issues are more precisely defined; (3) the guidelines product will be more responsive to the problems of most interest to clinicians, patients, and other users; and (4) the implementation and evaluation of the guidelines should be easier. Recognizing that expectations such as these are not always borne out, the committee also recommended that the Forum should plan a future assessment of whether attempts to define topics more precisely have actually met expectations. The committee heard some suggestions that guidelines developers should abandon the focus on clinical problems and concentrate on specific alternative technologies. Generally, the committee did not find the arguments for such a wholesale shift persuasive. An initial focus on clinical conditions encourages (1) a broad view of patient care issues and alternatives (including preventive, diagnostic, and treatment strategies) and (2) an emphasis on health problems and outcomes of care as they are experienced, managed, or evaluated by patients, clinicians, and health care organizations. The committee concluded that the Forum should generally continue to direct its attention toward clinical problems, although the priority-setting process should not completely preclude the nomination or selection of technology-based topics. The committee recognizes that government agencies and private organizations also need technology-specific assessments to guide decisions about whether Medicare or other health plans should cover certain procedures, drugs, or devices or whether hospitals or other organizations should purchase particular equipment. The advice provided by clinical practice guidelines may not be sufficient for these decisions. In contrast to the AHCPR's Forum, one mission of the agency's Office of Health Technology Assessment is to conduct assessments that support such decisions. Defining narrower topics will likely require modifications in some aspects of the current priority-setting process. Such changes would begin with the way nominations for topics are solicited and extend through steps involving the use of expert judgment and the development of consensus. Staff will have to develop new instructions that include specific examples of topics that are too broad (e.g., pain management). In collecting information about proposed topics, staff will have the opportunity to identify snore specific definitions of a topic. In addition or alternatively, the Forum might consider defining "packages" of topics that divide a significant issue into smaller components (e.g., by population or care setting) that could be dealt with sequentially by the Forum or in partnership with other organizations. Again, even if topics are more narrowly defined initially, the committee expects that guideline panels will still have to

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FUTURE DIRECTIONS FOR PRIORITY SETTING 63 devote some time to further defining the clinical problem and the characteristics and needs of relevant populations, care settings, and providers. NATIONAL AND LOCAL GUIDELINES By defining topics more precisely at the outset, the Forum should help guidelines panels respond to another criticism that the guidelines themselves are sometimes too ambiguous or incomplete to be readily implemented or used by clinicians and others. With narrower topics, it seems likely that panels would be in a better position to devise more specific statements about appropriate practice and expected outcomes. Nonetheless, increasing experience with guidelines suggests that it is unreasonable indeed impossible-to expect nationally developed practice guidelines to cover every operational issue for every kind of setting, practitioner, and patient or to specify care processes in sufficient detail to be directly integrated into practice by all relevant users. The evidence base for such comprehensive statements is seriously inadequate, and the multiplicity and variability of local delivery arrangements are difficult even to catalog much less reflect in recommendations. Yet, guidelines that leave too much to be decided at the local level or during implementation run the risk of being ignored, misused, and modified in ways detrimental to patients. In an earlier report on practice guidelines, another IOM committee described several circumstances that might prompt local organizations to adapt guidelines (IOM, 1992a). They include (1) general weaknesses in the guidelines unrelated to particular local circumstances; (2) inconsistent guidelines from different sources; (3) specific local or organizational objectives or constraints; (4) strategic judgments about the need to secure practitioner acceptance and agreement to changes in practice; and (5) protection of habit or self-interest. In the first category are included familiar problems with guidelines, such as lack of sufficient specificity about different patient categories, inattention to outcomes, failure to relate recommendations to evidence, and poor presentation or fonnatting (Borbas, McLauglin, and Schultz, 1993~. Improvements in the quality of guideline development efforts and their products are diminishing some of these problems. Likewise, the growing acceptance of clear, evidence-based guidelines should curtail unwarranted and inappropriate modifications. In any case, some review and adaptation of national guidelines may be a reasonable price to pay for acceptance of guidelines and

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64 SEITING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES commitment to their application, as long as the departures can be defended as having minimal or no negative effect on patient well-being.) The rapid restructuring of the health care system adds both urgency and complexity to the task of evaluating how national and local groups can work together to improve the quality and effectiveness of health care. In this context, the committee made an inexact but convenient distinction between organizations that develop guidelines for use by others (national programs) and those that both develop and apply them in health care settings (local programs). A pertinent question is how roles in guideline development for national and local organizations can be defined in ways that draw on the strengths of each and minimize their limitations. The committee considered this question as it looked more generally at fixture directions for AHCPR and the Forum. FUTURE ROLES FOR AHCPR During the committee's August workshop and in other forums, AHCPR staff and others have raised the question of whether the Forum should reduce or abandon its involvement in guidelines development (MOGA, 1994b). Should AHCPR cede guidelines development to others? In this committee's view, the answer at least for now is no. Although the number of groups involved in guidelines development is larger than when AHCPR was created, the Forums work is more visible and inclusive than most, making its activities more accessible as examples or prototypes frown which others can learn both positive and negative lessons. The value of this experience is, however, likely to diminish as the methodological, procedural, and other challenges of guidelines development are better resolved and as agreement on preferred approaches grows. Thus, the continuing contribution of AHCPR involvement in the fimction should be reevaluated periodically. In addition, as a public agency, AHCPR selects guidelines topics that are not high priorities for other groups. For instance, the pressures of health care restructuring may lead private organizations developing guidelines to underrate guidelines for practice in areas in which managed care incentives may encourage undertreatment, disregard for patient preferences for different care options, or inattention to the problems of uninsured and otherwise disadvantaged populations. iThe earlier committee also argued that when local institutions do adapt national guidelines, one useful step would be for them to notify the originating group and to explain the circumstances that led to their modifications. The Forum, in its work on guidelines dissemination and implementation, has tried to organize such feedback as part of test projects involving some of its guidelines.

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FUTURE DIRECTIONS FOR PRIORITY SEWING 65 AHCPR-sponsored guidelines have been relatively costly, and the organization needs to find cost-reduction strategies. The Forum should be able to improve the efficiency of its guidelines development activity by better defining and targeting topics during the priority-setting process and by developing a procedure manual for the typical activities and documents involved in developing guidelines. The committee further suggests that the Forum build on its current work in both development and implementation to design and test alternative models of guideline development that include both national and local components. A Two-Stage Approach to Guidelines Development As generally envisioned by this committee, the alternative models for guidelines development would have two stages, one "national," the other "local." The first phase would be similar to the current AHCPR process in some respects.2 The review and analysis of the scientific evidence would be a core activity, capitalizing on the agency's ability to mobilize expertise for this purpose.3 The reviews would continue to be the foundation for evidence-based statements to assist clinician and patient decisionmaking. The final steps in this phase of the development process would be to help structure the second phase, for example, by specifying outcomes arid other relevant measures and by identifying key process-of-care questions as priorities for further work. The second phase of the new guidelines development process would shin activity Mom the national to the local level. Work at that level would involve a combination of two steps: (1) farther "specification" of the guidelines (e.g., process-of-care protocols) and (2) operational tests of the resulting guidelines. One or more organizations directly involved in health care delivery would have primary responsibility for conducting this work. 2It is possible that this work could be satisfactorily (and more efficiently) handled by a standing panel supplemented by additional topic-specific experts. Such an approach would be similar to that used by the American College of Physicians and the U.S. Preventive Services Task Force. 3The committee did not discuss literature reviews and analyses of evidence in any depth but recognized the importance of assigning the task to experts highly qualified for this specialized task. Such experts may not be among the participants in the panel developing a set of guidelines. Panel members should not be expected to provide the primary analysis of evidence unless they have requisite skills and time.

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66 SETTING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES With a two-phase development strategy, the kind of protocol development activity for pressure ulcers described in the background paper by Horn (Appendix D) would be anticipated and planned from the outset of the effort to develop the AHCPR guidelines. The products of such an approach might still have to be modified to account for myriad local operating differences (e.g., staffing levels, physical plant characteristics). Nonetheless, this joint national-local strategy would challenge those who would modify the guidelines to develop evidence that their modifications improved patient care or permitted equivalent care at lower cost. A number of questions about this strategy need further consideration. Do all AHCPR guidelines topics warrant this approach? Could the phase two participants feasibly be identified at the beginning of the development process, or would that be premature? What does the two-phase approach imply for the timetable and cost of guidelines development (assuming more precision and some narrowing in topic definition)? How might the guidelines be tracked as they diffused to determine why modifications were made and with what effect? In sum, because the AHCPR has responsibilities for encouraging and evaluating the implementation of practice guidelines, the committee urged that it support projects that focus on the critical and sometimes imprecise boundary between the development and implementation of guidelines. The approach proposed here would move in that direction. Aside from the policy issues noted above, other important questions demand attention. To what extent are local organizations now involved in guidelines development, and to what extent does their work build on, ignore, or even contradict national guidelines? How consistent are the products of local efforts? Are inconsistencies a problem? To what extent can or should local guidelines be generalizable to other institutions? These are questions that should concern all parties involved with clinical practice guidelines. The Forum as Clearinghouse In 1985, an IOM council recommended the creation of "a central clearinghouse to monitor, synthesize, and disseminate information about all medical technology assessments" including those developed outside the United States TOM, 1985, p. 61~. Several years later, another committee considered how a clearinghouse for practice guidelines might be structured. That committee identified the main issues as (1) the actual aloud perceived integrity ofthe process, participants, and results and (2) the sufficiency of the resources applied to the task. It recommended the creation of a public-private entity to undertake the clearinghouse function because it concluded that neither a purely public nor a purely private organization would have sufficient credibility with practitioners, payers, and other key groups with dissimilar perspectives and concerns.

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FUTURE DIRECTIONS FOR PRIORITY SEITING 67 The current committee concluded that a government-based clearinghouse might now be more acceptable to disparate interests, in part because both guidelines and the principles for developing and using them have become more accepted. In addition, the committee noted the difficulty of creating and sustaining joint public-private initiatives.4 A number of important questions need, however, to be considered before AHCPR launches a clearinghouse. They Include the following What would a clearinghouse function involve in the context of the agency's statutory responsibilities? How should the private sector be involved substantively, financially, or otherwise? Who are the potential audiences for the products and services of a clearinghouse? What are their interests, arid how much do they overlap? Should the interests of particular audiences (e.g., managed care organizations) be given preference? Is there an international audience that should be considered given AHCPR's status as a leader in guidelines development and dissemination? What can be learned from similar existing efforts (e.g., the American Medical Association's clearinghouse)? What should be the scope of the effort? Should the initial emphasis be placed on defining a relatively narrow scope (e.g., specific clinical areas, competing guidelines, guidelines developed by organizations that also implemented and evaluated them), with additional activities phased in as experience accumulates? What are the means for identifying potential guidelines for clearinghouse consideration and what criteria should guide the process? What information would those who had developed practice guidelines be expected to provide either for the agency's use or for general distribution or for both? These questions lead to another important aired difficult question: to what extent should a clearinghouse include an assessment component? That is, should it just pass guidelines along to interested parties or should it screen them in some way? If the latter, should it just screen out deficient guidelines or should it 4For example, a 1982 Office of Technology Assessment (OTA) report described as an option and a 1983 IOM report recommended the creation of a public-private technology assessment consortium (OTA, 1982; IOM, 1983~. In 1984, legislation established the Council on Health Care Technology at the IOM, but its complex private- sector funding requirements proved unworkable, and it was discontinued in 1989. A more recent effort to channel private funds to increase federal technology assessment activities also was unsuccessful (Kent, 1991).

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68 SETTING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES provide users with an assessment of each set of guidelines? Should it go further and actually certify guidelines as "acceptable?" What criteria should be used in screening? Assessing Guidelines Developed by Other Organizations One factor the Forum now considers in determining whether it should proceed with guidelines on a particular topic is whether sound guidelines from other organizations are already available. This is a reasonable basis for decisionmaking, but it raises the question of how these other guidelines are to be assessed. This is especially the case if the Forum, as has been suggested to the committee, focuses less on developing guidelines and more on encouraging and disseminating guidelines developed by others. Assessment as used here means prospective consideration of the strengths and weaknesses of a set of guidelines, not the subsequent evaluation of the impacts of guidelines on costs, quality, and other factors. Just as the Forum should have explicit, open, and defensible methods for setting priorities for guidelines development, it should likewise have explicit, open, and defensible processes for assessing the soundness of guidelines developed by other organizations. The soundness of all existing guidelines certainly cannot be assumed. Extent of Activity. In considering the role of AHCPR in assessing guidelines developed by others, the committee distinguished three options. The first option provides a minimal role in which guidelines would be assessed only to determine whether a high-priority topic being considered by the Forlorn for guidelines development is already covered by acceptable existing guidelines. The second option would have the Forum examine a broader range of guidelines as part of an augmented clearinghouse function that would provide potential users with some information about the strengths and limitations of guidelines developed by other organizations. (This option might also encompass some kind of certification process.) The third option is for the Forum to follow assessments, when appropriate, with a guidelines development process intended to clarify ambiguities, conflicts, or other problems with existing sets of guidelines. For each option, a major question is what methodology the Forum might employ to examine existing guidelines. Methods and Process. The 1992 report ofthe IOM Co~nn~ittee on Clinical Practice Guidelines included a provisional instrument for assessing guidelines (IOM, 1992a). The instrument was provisional because the previous committee believed it needed further testing and revision. Since then, the instrument has

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FUTURE DIRECTIONS FOR PRIORITY SETTING 69 been tested by at least two organizations and has been used more generally to guide assessments in other instances (Gifford, 1994; Cluzeau et al., 1994~. The current report like its predecessor recommends that the Forum sponsor further evaluation of this and similar instruments. If the Forum undertakes a broader assessment role, how should the results of an assessment be presented? Again, this report like its predecessor recommends that the emphasis should not be placed on simple approval (or endorsement) or disapproval of a set of guidelines. Rather, in the spirit of Consumer Reports, the objective should be to let the various potential users of guidelines understand where the strengths and weaknesses of a particular set of guidelines lie. This approach does not, however, preclude a judgment that a particular guideline is so deficient that it deserves an "unacceptable" rating or that another guideline is clearly superior, that is, the equivalent of a "best buy." Proficiency or Performance Guidelines Another potential future role for the Forum involves procedure- or task- specific proficiency or performance guidelines. Unlike practice guidelines that assist practitioners and patients in deciding what course of care is appropriate (e.g., surgery or "watchful waiting"), proficiency or performance guidelines would set forth methods and measures for assessing an individual practitioner's competence in carrying out a specific task (e.g., a surgical procedure). Although such guidelines could apply to either established or emerging technologies, much ofthe interest in proficiency assessment stems from questions about the adequacy of strategies for educating licensed practitioners and assessing their competences in using new technologies (e.g., laparoscopic cholecystectomy, dental implants, radial keratotomy). Conceptual and methodological problems have historically complicated efforts by educators, hospital officials, state licensing bodies, and others to assess and ensure professional competence in general and with respect to specific skills or tasks. The issue of competency assessment is becoming increasingly visible as managed care plans expand and seek both to restrict the numbers of participating physicians and to reallocate clinical tasks. Reallocation strategies may focus on the division of labor between generalist and specialist physicians, between physicians and nonphysicians, among different nonphysician groups, and within nonphysician groups such as nursing. Proficiency or performance guidelines might be useful if they provided a competence-based justification for decisions about privileges, credentials, arid rei~nburse~nent, although their usefulness might at first be largely limited to decisions about individuals in the same professional category. AHCPR might wish to consider whether some part

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70 SETTING PRIORITIES FOR CLINICAL PRACTICE GUIDELINES of the agency should pursue work in this area as an extension of the organization's activities in outcomes and effectiveness research. Coordination with Other Government Agencies A perennial issue in government, indeed in most complex organizations, is coordination (Pressman end Wildavsky, 1984~. That is, how can the structures and processes of the organization be arranged so units are not engaging in duplicative tasks or producing conflicting products? The perennial caution about proposals to improve coordination is that the task is neither easy nor costless. Coordination efforts that begin energetically and optimistically often expire quietly as bureaucratic procedures and interunit negotiations multiply. The committee commended the U.S. Deparunent of Health and Human Services for its efforts to map the technology assessment and guidelines activities of its various units. However, it urged that efforts to coordinate or reassign guidelines activities be guided by a strong and realistic regard for their potential for success and their likely costs as well as for their hoped-for benefits. CONCLUSION The committee believed that AHCPR should continue to play an important role in sponsoring and otherwise encouraging the development and implementation of evidence-based guidelines that are credible and useful to clinicians, patients, and others. In support of this judgment, the committee offered recommendations for improving the agency's priority-setting process, including its methods for assessing whether guidelines already developed by other organizations provide adequate assessments and recommendations. The committee also suggested ways to promote the movement of guidelines from publication to implementation through narrower and more precise definition of topics and through phased national and local development and refinement of guidelines. The committee believed the agency could also play an important clearinghouse role in identifying and disseminating guidelines developed by other public and private organizations. A key question is whether the agency should provide potential users with assessments of the soundness of such guidelines. The committee recommended further work to test assessment instruments developed by the IOM and others. Although expectations for quick results have been somewhat tempered since AHCPR was created in 1989, the guidelines enterprise still requires patience and commitment. The achievements of AHCPR's Forum should be acknowledged and its deficiencies regarded as the occasion not for punishment but for learning and improvement. Finally, as the pressures to reduce costs and accommodate the

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FUTURE DIRECTIONS FOR PRIORITY SETTING 71 operational realities of a competitive health care market intensify, clinical practice guidelines should still be developed-and implemented with regard for the complexity and intimacy of the relationship between patient and practitioner as they face both the mundane and the critical challenges of maintaining good health, treating illness, and protecting personal dignity.

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