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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 63 various sets of guidelines. In the case of medical review criteria, additional staff may be required to handle inquiries. This report does not take a position on whether costs should be explicitly factored into recommendations, although some committee members have strong views that such a step should be mandatory if guidelines are to control costs. The committee did agree that information on projected health outcomes and costs will help developers and users of guidelines better understand the implications of following or not following the guidelines. One part of this process will be some clarification of both the factual and the value judgments involved for practitioners, patients, health plans, and others in making such decisions. In some cases, a patient may decide that a service is not worth the personal out-of-pocket cost; in others, a provider may choose among clinically acceptable alternatives on the basis of financial considerations, such as the opportunity cost of acquiring new equipment. Similarly, a health benefits plan may opt not to cover a category of service that it is quite appropriate for a practitioner to provide and a patient to receive.4 Relationship Between the Evidence and the Guidelines Practice guidelines have not always been clearly and consistently related to the scientific and clinical evidence (Eddy and Billings, 1988), but they should be. The link between the base of evidence and a set of guidelines needs to be explicit, preferably with specific citations for specific portions of a set of guidelines. This implies the need for a reference list rather than just a bibliography of literature used in the guidelines development process. A bibliography may, however, indicate sources consulted but not cited. Preference for Empirical Evidence Over Expert Judgement Empirical evidence should take precedence over expert judgment in the development of guidelines. When the empirical evidence has important limitations and experts reach conclusions that are not consistent with the evidence, then the conflict and limits of the evidence should be clearly described and the rationale for departing from the evidence, such as it is, should be explained. When expert judgment proceeds in the absence of 4 For example, childhood immunizations and other preventive services have traditionally been excluded from indemnity health plans because insurers believe it is actuarially unwise to cover smaller, more predictable expenses that their subscribers can budget. Competitive pressures from health maintenance organizations may sometimes offset these beliefs, but this may reflect marketing more than clinical considerations.