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INTRODUCTION AND BACKGROUND 20 The IOM agreed to appoint a study committee that would work quickly to provide technical assistance and advice on definition of terms, specification of key attributes of good guidelines, and certain aspects of planning for implementation and evaluation. This report largely confines itself to these specific and limited tasks.1 It is not a how-to-do-it manual, a methodology text, a priority-setting exercise, or a primer on guidelines for those seeking an introduction to the subject. The report does, however, also aim to encourage more standardization and consistency in guidelines development, whether such development is supported directly by the Forum or is undertaken independently by medical societies and other organizations. The committee believes that the AHCPR initiative, taken as a whole, has real potential to advance the state of the art for practice guidelines, strengthen the knowledge base for health care practice, and, hence, improve the appropriateness and effectiveness of health care. One objective of this report is to encourage realistic expectations about this potential by building a broader understanding of the difficult but important steps needed to move toward the goals for guidelines stated in P.L. 101-239, or, as it is often called, the Omnibus Budget Reconciliation Act of 1989 (OBRA 89). CONTEXT The legislation establishing AHCPR is one consequence of accumulated public and private frustration about the perceived health and economic consequences of inappropriate medical care. This frustration and the perceptions that give rise to it stem from many sources including ceaselessly escalating health care costs, wide variations in medical practice patterns, evidence that some health care services delivered in this country are of little or no value, and claims that various kinds of financial, educational, and organizational incentives can reduce inappropriate utilization (IOM, 1989). The combination of high levels of expenditure and doubts about the value of that spending explains policymakers' interest in improving the scope and application of knowledge about what works and what does not work in medical careâand at what price. AHCPR is supporting an extensive agenda of outcomes and effectiveness research to add to the knowledge developed through other sources such as the randomized clinical trials funded by the National Institutes of Health. In fact, the major part of the agency's 1 In addition, in May 1990, the IOM embarked on a new 18-month project funded by the John A. Hartford Foundation, Inc., and the Public Health Service to study both public and private activities to develop, use, and evaluate guidelines and to recommend a framework for better structuring of these activities where that is desirable and feasible (see Appendix C). The report of this study is planned for release in the fall of 1991.