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INTRODUCTION AND BACKGROUND 22 attention been paid to evaluating whether and why guidelines have any impact. Public Initiatives Under OBRA 89, AHCPR has responsibilities in several areas: (1) health services research including research on effectiveness, efficiency, and quality of health care with a particular emphasis on outcomes research; (2) development, collection, and dissemination of data; (3) health care technology assessment; and (4) practice guidelines. To promote activities in the area of practice guidelines, Congress created a unit within AHCPR, the Office of the Forum for Quality and Effectiveness in Health Care. As described in more detail later in this chapter, the Forum must "arrange for" the development and periodic review and updating of (1) clinically relevant guidelines that may be used by physicians, educators, and health care practitioners to assist in determining how diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically; and (2) standards of quality, performance measures, and medical review criteria through which health care providers and other appropriate entities may assess or review the provision of health care and assure the quality of such care. As explained by one individual intimately involved in the development of this legislation, the phrase arrange for is one key indicator of the "extent to which the legislation was structured to create a public-private enterprise with respect to guideline development. The Forum develops no guidelines; guidelines are not to be federal creations" (Peter Budetti, George Washington University, personal communication, July 13, 1989). The committee suspects, nonetheless, that most people will continue to use the term develop to describe what the Forum does in this area. Other agencies of the federal government have or have recently had responsibilities related to practice guidelines. These agencies include the National Institutes of Health, the U.S. Preventive Services Task Force,2 and the Health Care Financing Administration (HCFA) and its contracting carriers, fiscal intermediaries, and peer review organizations. HCFA and its contractors have developed criteria for reviewing services provided to Medicare beneficiaries. These criteria and their application, neither of which are examined here, have been criticized for lack of rigor and accountability (Institute of Medicine, 1990; Physician Payment Review Commission, 1988a, 1989). 2 The Guide to Clinical Preventive Services prepared by the U.S. Preventive Services Task Force (1989) is a useful text to read in conjunction with this report, although this report is not specifically cross-referenced to the guide.