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DEFINITIONS OF KEY TERMS 41 labeled equivocal for empirical reasons; that is, the benefits and harms are uncertain. It might also be described as equivocal because of ambivalence, for instance, when the benefits are known to exceed harms but to such a trivial or small degree that raters are reluctant to call the practice appropriate. In this latter case, value judgments may have much to do with whether a practice is considered "worth" providing (or receiving), and these judgments may rest on considerations of cost and other matters. Guidelines and Costs The committee's definition of appropriate care does not require that guidelines be based on judgments about the cost-effectiveness of particular clinical practices; neither does it preclude it. As discussed in Chapter 3, the committee concludes that, insofar as feasible, developers of guidelines should consider costs and should include information with the guidelines that allows others to make their own cost- benefit or cost-effectiveness judgments. The committee's decision not to incorporate an explicit reference to costs in the definition of practice guidelines or appropriate care reflects a value judgment that was not shared by all committee members. The majority, however, believed that the emphasis on clinical decisionmaking should be paramount. In addition, some committee members strongly disagreed with the committee's decision not to refer explicitly to third-party payers and others in the definition of practice guidelines. As a practical matter, OBRA 89 requires that the needs of the Medicare program and peer review organizations be considered by AHCPR in selecting topics for guidelines development, encouraging the dissemination and use of guidelines, and evaluating their impact. In addition, the agency must arrange for the development of medical review criteria and other practice evaluation tools. These factors appear sufficient to ensure that the needs of payers, consumer groups, and similar parties will be addressed during the guidelines development stage. EVALUATION INSTRUMENTS As defined above, practice guidelines are meant to assist patients and practitioners in making health care decisions. Medical review criteria, standards of quality, and performance measures, which the committee groups together as practice evaluation instruments, are designed to assist health care organizations, payers, and others (including practitioners and payers themselves) in evaluating those decisions and health outcomes. Sometimes such evaluations will focus on individual instances of care (for example, to determine whether a hysterectomy is appropriate for a patient