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SUMMARY 3 as a foundation for instruments to evaluate practitioner and health system performance. OVERVIEW OF PRACTICE GUIDELINES INITIATIVES Public and private activities related to practice guidelines can be conceptualized, ideally, as having three basic stages: development, intervention, and evaluation. The second and third stages shouldâagain ideallyâinvolve feedback loops to the first stage to prompt the revision of guidelines when omissions, technical obsolescence, or other problems with a set of guidelines are identified. Guidelines are thus dynamic, not static. They reflect the interplay of scientific and technological progress, real-world organizational pressures, and changes in social values. To date, most government and other initiatives emphasize the first of the three stages, the development of guidelines. Public Initiatives Under OBRA 89, Congress created within AHCPR the Office of the Forum for Quality and Effectiveness in Health Care. 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. The phrase "arrange for" is one key indicator of the extent to which the drafters of OBRA 89 sought to create a public-private enterprise with respect to guidelines development. Their vision was that the Forum would itself develop no guidelines; guidelines were not to be federal creations. By January 1, 1991, the Forum must arrange for the development of an initial set of guidelines, standards, performance measures, and review criteria for at least three clinical treatments or conditions. The agency is also responsible for updating the guidelines developed under its auspices. Other key provisions of the legislation include the following. â¢ The Forum can contract with public and nonprofit private organizations to develop and update guidelines, or it can convene expert panels to either develop guidelines or review guidelines developed by contractors. â¢ The director of the Forum must establish the standards for methods and procedures to be followed by the contractors and expert panels. The guidelines can be pilot-tested.
SUMMARY 4 â¢ Guidelines developed by private organizations independently of the agency program may be adopted by contractors or expert panels if they meet the requirements established by the legislation. â¢ The director of the Forum is to promote dissemination of guidelines through organizations representing health care providers, health care consumers, peer review organizations, accrediting bodies, and other appropriate entities. In addition, the guidelines must be presented in formats appropriate for use by practitioners, medical educators, and medical care reviewers. â¢ The Secretary of the Department of Health and Human Services (DHHS) "shall provide for the use of the [initial sets of] guidelines . . . to improve the quality, effectiveness, and appropriateness of care" provided under the Medicare program. Presumably, providing for the use of the guidelines will require that the Health Care Financing Administration (HCFA) and its contracting fiscal intermediaries, carriers, and peer review organizations take steps to incorporate review criteria and other evaluation instruments into their programs for reviewing care provided to Medicare beneficiaries. â¢ The director of the Forum is to conduct and support evaluations of the impact of guidelines on clinical practice. More specifically, for the guidelines developed by January 1, 1991, the Secretary of DHHS must determine the impact of the initial sets of guidelines on the cost, quality, appropriateness, and effectiveness of medical care provided under the Medicare program and report the results to Congress by January 1, 1993. â¢ With respect to the research agenda of AHCPR, the director of the Forum is to recommend research projects related to the outcomes of health care, the processes for developing guidelines, and the use of guidelines. In general, when it examines clinical conditions as potential subjects for guidelines, the agency is instructed to consider how guidelines, standards, performance measures, and review criteria can be expected to (1) improve health for a significant number of individuals, (2) reduce clinically significant variations in services and procedures provided by physicians, and (3) reduce clinically significant variations in the outcomes of health care. Moreover, the administrator of the agency is to consult with the Health Care Financing Administration and ensure that the needs and priorities of the Medicare program are appropriately reflected in the development of guidelines. For the initial three sets of guidelines, the legislation provides more specific selection priorities related to expenditures and services for Medicare beneficiaries. In addition to the new agency, other agencies of the federal government have related responsibilities. These agencies include the National Institutes of Health (NIH), the U.S. Preventive Services Task Force, and