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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 56 its expert panels; it is fundamental that the Forum instruct developers of guidelines on the desired properties of guidelines and on the documentation needed as a basis for assessment. As mentioned earlier, the development of a formal instrument for assessing guidelines is an important next step for this committee. More generally, the number of attributes must be sensible and practical. An appropriate balance must be reached between enough attributes to allow adequate assessment of the guidelines but not so many that the assessment exercise becomes infeasible, confusing, or excessive, given limited resources. It is likely that an instrument for assessing guidelines will need to weight the eight attributes in some manner, specifying which of them are more significant in determining whether a given set of guidelines are sound. Given its time and resource constraints, this committee did not systematically rank the different attributes by relative importance, although the discussion below does distinguish some of the more important ones. A final point: this report differentiates between the priorities for selecting particular targets for guidelines and the desirable attributes of guidelines. The attributes listed in this chapter do not incorporate the OBRA 89 provisions requiring that priorities for the development of guidelines reflect the needs and priorities of the Medicare program and include clinical treatments or conditions accounting for a significant portion of Medicare expenditures. The legislation also calls on the Secretary of Health and Human Services to consider the extent to which guidelines can be expected "(i) to improve methods of prevention, diagnosis, treatment, and clinical management for the benefit of a significant number of individuals; (ii) to reduce clinically significant variations among physicians in the particular services and procedures utilized in making diagnoses and providing treatment; and (iii) to reduce clinically significant variations in the outcomes of health care services and procedures." In arriving at its eight recommended properties of guidelines, the committee did not incorporate these factors. Priority setting is a crucial but separate task and one that IOM has undertaken as part of other studies (IOM, 1990a,b,c,e). PAST WORK ON DEFINING ATTRIBUTES This committee considered three primary sources in identifying attributes for practice guidelines: (1) the legislation, (2) the IOM report on quality assurance for Medicare, and (3) work by the AMA. Other important materials, which in some cases were used in the primary sources, include the work of Brook, Chassin, Eddy, Greenfield, and their collaborators, as cited elsewhere in this report. In addition to describing priorities to guide the Forum in selecting
