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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 57 topics for guidelines, OBRA 89 sets forth some characteristics that guidelines should have. The committee distinguished these four points from the legislation. 1. Guidelines should be based on the best available research and professional judgment regarding the effectiveness and appropriateness of health care services and procedures. 2. The Forum director is expected to ensure that appropriate, interested individuals and organizations will be consulted during the development of guidelines. 3. The director has the power to pilot-test the guidelines. 4. Guidelines should be presented in forms appropriate for use in clinical practice, in educational programs, and in reviewing quality and appropriateness of medical care. A second major source for the committee's work, the IOM report on a quality assurance strategy for Medicare (1990d), included a chapter on attributes of quality of care and appropriateness criteria. These attributes derived from a June 1989 meeting of experts on the construction and use of practice guidelines. Some of the distinctions proposed by the quality panel are not used here. For example, this committee's report emphasizes key attributes of good guidelines but contains relatively little discussion of desirable but less critical attributes. In addition, this report drops the panel's distinction between substantive and implementation guidelines because the committee found it awkward to label every attribute as either one or the other. The point that lay behind the original distinction should, nonetheless, be stressed: the designers of guidelines need to keep implementation in mindâwhether and how the guidelines can be used. A third source considered by the committee was the AMA's booklet, "Attributes to Guide the Development of Practice Parameters" (1990a), which sets forth five attributes. They are (minus their accompanying discussion and more detailed descriptions) as follows: (1) practice parameters should be developed by or in conjunction with physician organizations; (2) reliable methodologies that integrate relevant research findings and appropriate clinical expertise should be used to develop practice parameters; (3) practice parameters should be as comprehensive and specific as possible; (4) practice parameters should be based on current information; and (5) practice parameters should be widely distributed. ATTRIBUTES FOR ASSESSING PRACTICE GUIDELINES: OVERVIEW The art of developing practice guidelines is in an early stage, and the strengths and weaknesses of specific approaches are still being debated. As a consequence, the committee recognizes that what is expected of