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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 68 A second kind of reliability that is important for practice guidelines is clinical reliability. Practice guidelines are reliable ifâgiven the same clinically relevant circumstancesâthe guidelines are interpreted and applied consistently by practitioners (or other appropriate parties). That is, the same practitioner, using the guidelines, makes the same basic clinical decision under the same circumstances from one time to the next, and different practitioners using the guidelines make the same decisions under the same circumstances. Pretesting of guidelines in actual delivery settings or on prototypical cases can help test this kind of reliability as well as contribute to assessments of validity. For medical review criteria and other specific tools for evaluating health care actions or outcomes, the concept of reliability (or reproducibility) seems straightforward. Ideally, review criteria and other tools for evaluating performance should be pretested to provide evidence that they meet a specified level of reliability over time for the same user (test-retest reliability) and between users (interrater reliability). Review criteria often run into reliability problems when they use undefined termsâsuch as "frequent" or "serious" or "presence of comorbid conditions"âthat different users may interpret quite differently. Thus, one tactic developers of guidelines and review criteria should use to maximize reliability is to avoid such terms unless precise definitions are provided. CLINICAL APPLICABILITY Because of the considerable resources and opportunity costs involved in developing practice guidelines, guidelines should be written to cover as inclusive a patient population as possible, consistent with knowledge about critical clinical and sociodemographic factors relevant for the condition or technology in question. For instance, a guideline should not be restricted to Medicare patients only through age 75 or through age 85 if evidence and expert judgment indicate that the clinical condition or the technology in question is pertinent to those over age 85. This attribute requires that guidelines explicitly describe the population or populations to which statements apply. These populations may be defined in terms of diagnosis, pathophysiology, age, gender, race, social support systems, and other characteristics. The purpose of such a definition is to help physicians concentrate specific services on classes of patients that can benefit from those services and avoid such services for classes of patients for whom the services might do harm or produce no net benefit. Again, the relevant scientific literature needs to be cited or its absence noted.
