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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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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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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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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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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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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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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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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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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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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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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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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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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
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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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Representative terms from entire chapter:
guidelines development
