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Suggested Citation:"WORKING ASSUMPTIONS." Institute of Medicine. 1990. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: The National Academies Press. doi: 10.17226/1626.
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Page 54

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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 54 to prepare a practical assessment instrument that the Forum can use to systematically review guidelines developed by its panels or by other groups (Appendix C). During the committee's deliberations, a question was raised about whether the Forum has formal authority under OBRA 89 either to reject or approve the guidelines developed by its contractors or expert panels. This report does not speak to that legal point. Nevertheless, regardless of the Forum's statutory authority in this regard, it is reasonable that the agency should examine the soundness of guidelines developed under its auspices. This examination may (1) improve the way the agency works with contractors or panels in the future, (2) contribute to more informed consideration of dissemination options and evaluation strategies, (3) allow more sophisticated consultations with HCFA and other government agencies about their use of the guidelines, and (4) provide feedback about the feasibility of the assessments proposed here. In this report, assessment means the prospective or initial judgment of the soundness and feasibility of a set of guidelines. In contrast, the empirical evaluation of the cost, quality, and other effects of guidelines occurs after they are published and implemented. Further, a set of guidelines includes a series of statements or recommendations about appropriate practice and the accompanying descriptions of evidence, methodology, and rationale. A guideline in the singular refers to a discrete statement or recommendation (for example, annual breast physical examination for women aged 40 to 49 with no family or personal history of breast cancer). Each of the appropriateness reports published by the RAND Corporation clearly exemplifies a set of guidelines (Park et al., 1986). Likewise, using this terminology, the report of the U.S. Preventive Services Task Force (1989) contains 60 sets of guidelines and not 60 guidelines. WORKING ASSUMPTIONS The committee's first working assumption has been that a set of guidelines will be assessed as a whole; that is, its elements will not be assessed individually in isolation. Under this assumption the Forum could judge a set of guidelines acceptable even if individual statements lacked—for legitimate reasons—some essential attributes. Realistically, early guidelines and (especially) existing guidelines are not likely to score well on all eight attributes collectively. However, the committee expects that, as the development process matures, guidelines will continue to comprise more and more of the attributes. Second, the committee assumes that the Forum will (in line with OBRA 89 provisions) convene expert panels to assess either existing guidelines or

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