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INTRODUCTION AND BACKGROUND 23 Private Initiatives Guidelines for clinical practice, broadly defined, are not new. The processes of organized clinical education require various sorts of guidelines as do the processes of professional licensure, board certification, quality assurance, utilization review, and other aspects of health services administration. However, in recent years, the interest in practice guidelines of the medical community and others has grown exponentially. The level of interest in guidelines is not all that has changed. Today, there is a much greater emphasis on formal procedures and methods for arriving at a more widely scrutinized and endorsed consensus about what is appropriate clinical practice. Among the medical groups involved for some years with the development of guidelines are the American Academy of Family Physicians, the American College of Cardiology, the American College of Physicians, and the American Society of Anesthesiologists. In the research community, the RAND Corporation has pioneered the development of important tools and strategies. Newer initiatives are being undertaken or planned by the American Board of Medical Specialties, the American Medical Association, the Council of Medical Specialty Societies, and the academic medical and health services research community. Insurers, health maintenance organizations (HMOs), utilization management firms, and similar organizations have not ignored the potential of practice guidelines as a basis for refusing payment for inappropriate care. For example, several years ago the Blue Cross and Blue Shield Association began its Medical Necessity Project, which supported and cooperated with researchers and some medical organizations in their efforts to identify obsolete procedures and set guidelines for the appropriate use of many diagnostic and treatment services. The Health Insurance Association of America recently established a similar function, and the Group Health Association of America has been sponsoring programs on guidelines development. Furthermore, individual members of each of these associations are involved in additional efforts to develop or adapt practice guidelines to meet the needs of their different health plans. In addition, the activities of dozens of firms supplying utilization management services to health plan sponsors have focused attention on the quality, scope, and accessibility of the criteria they use to review care on a prospective or concurrent basis. The guidelines development efforts of private organizations are thus proceeding on many fronts. Some coordinating strategies are emerging, but important problems remainâunexplained conflicts among guidelines, neglected topics, lack of follow-up, and incomplete public disclosure of the evidence, participants, and methods used to develop sets of guidelines. There is no independent entity to certify that guidelines are sound in