Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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8 A FRAMEWORK FOR THE FUTURE
8 A FRAMEWORK FOR THE FUTURE
Pages 196-219
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From page 196... ...
In this chapter, the committee responds to the second and third of its charges. It identifies some general strengths and limitations of current structures and processes for developing and applying clinical practice guidelines and then presents a framework for the future development, use, evaluation, and improvement of guidelines.
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From page 197... ...
GENERAL STRENGTHS AND WEAKNESSES OF CURRENT PRACTICE GUIDELINES ACTIVITIES Efforts to develop practice guidelines can be characterized, somewhat simplistically, as long-standing or embryonic. Many professional and provider organizations have for many years been creating and applying what they construe to be practice guidelines; for them, guidelines development and implementation is not new.
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From page 198... ...
A fourth strength is that researchers, clinicians, educators, and managers are being stimulated to consider how guidelines and other efforts to improve the quality and efficiency of health care can support and complement each other. These efforts include outcomes and effectiveness re search, methods for strengthening informed patient decisionmaking, and both traditional and newer techniques for quality assessment and quality Improvement.
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From page 199... ...
Methods and procedures for local adaptation of national guidelines and for translation of guidelines into medical review criteria have not been thoroughly documented, but they certainly appear to be subject to equal or greater weaknesses. Potential users of guidelines and review criteria have no ready means to judge the soundness of materials produced by different groups with different approaches.
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From page 200... ...
In varying degrees, practitioners, payers, risk managers, and those involved in quality assurance and improvement perceive that many guidelines fall short in their applicability to real-world circumstances and in their clarity and precision. The committee recognizes the considerable gaps in empirical information about the natural history of many diseases and conditions, about health outcomes for many diagnostic or therapeutic interventions, and about the costs of providing those (or alternative)
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From page 201... ...
Orderly processes for revising guidelines have yet to be implemented and may require some degree of assistance and coordination from AHCPR and such broad-based professional organizations as the American Medical Association. At the Interface Between Development and Use The committee also considered three subjects that arise at the interface between guidelines development and guidelines implementation: local adaptation of guidelines, inconsistent guidelines, and formatting and dissemination.
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From page 202... ...
Where carefully developed and documented "national" guidelines exist, local adaptation processes should provide explicit rationales that relate to specific, well-defined local conditions or objectives and that take notice of the strength of the case for the original guidelines. Inconsistent Guidlelines Inconsistent guidelines appear to be unavoidable, even for groups looking at the same scientific evidence and using defensible expertjudgment procedures.
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From page 203... ...
After much debate, the committee concluded that every set of guidelines need not be based on formal judgments of cost-effectiveness; sound guidelines for clinical practice can stand on rigorous assessments of clinical evidence and carefully derived expert judgment. In addition, the committee declinedwith some dissent to recommend that guidelines must include statements of what constitutes minimum or required care for particular clinical prob lems.
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From page 204... ...
Such "patient information guidelines" should be developed by a systematic process similar but not identical to that described for clinical practice guidelines. Once formulated, these guidelines would apply, unless specifically modified by condition-specific guidelines, to broad categories of patient care.
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From page 205... ...
Guidelines that have been accepted by those responsible for providing care, those responsible for financing it, and those responsible for monitoring care in the public interest are one means of bridging the chasm between internal and external quality assurance strateg~es. With respect to models of continuous quality improvement, the committee urges that their focus on systems problems, improvement of average performance, and reduction of variation be more systematically and explicitly joined with an effort to apply and improve sound guidelines for clinical practice.
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From page 206... ...
app. lcatlons; · Institutional activities to develop or adapt guidelines or review criteria should aspire to incorporate the attributes for guidelines and for review criteria described elsewhere in this report.
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From page 207... ...
The criticisms directed at the variability and weaknesses of review criteria developed or adopted by Medicare PROs and carriers (and the fact that the criteria of the latter groups are often kept secret as well) made the committee reluctant to accept organizational imprimatur alone as a sufficient basis for a grant of immunity.
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From page 208... ...
The clinical and health services research communities also have a role to play in smoothing the path from clinical research to better clinical practice and improved health outcomes. If more attention is paid to testing the effectiveness of procedures and patient management strategies in real-life settings rather than only assessing efficacy in highly controlled clinical trials, developers of guidelines will be more likely to have a knowledge base with greater practical relevance.
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From page 209... ...
The resulting comments and suggestions, which were both extensive and candid, reinforced the committee's initial assumption that the instrument required more practical testing of its utility.2 The assessment instrument covers both the process used to develop a specific guidelines document and the substantive content of the document and its recommendations. (The committee did not want an assessment instrument that could allow a set of scientifically invalid or questionable guidelines to receive a "good" rating based on process criteria alone.)
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From page 210... ...
Assessment Organization Given a reliable, valid assessment instrument, how might one apply it in a broader evaluative program? The above discussion of the instrument implies little about the characteristics of a specific institutional arrangement for assessing guidelines except that it would require more than trivial resources and stature.
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From page 211... ...
3 The Council on Health Care Technology was established at the Institute of Medicine through the Health Promotion and Disease Prevention Amendments of 1984, partly in response to a recommendation in the 1983 IOM report, A Consortium for Assessing Medical Technologies; it was reauthorized in 1987. A complex system of public and private funding, which essentially called for private-sector financing to be acquired and spent before certain public matching monies (through the National Center for Health Services Research, or NCHSR)
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From page 212... ...
an excellent understanding of actual clinical practice as well as a thorough grounding in clinical research, research methodologies, outcomes measurement, and cost-effectiveness analysis. · Stability of effort.
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From page 213... ...
To forestall criticisms about objectivity and integrity, the board of any such organization would develop clear procedures regarding bias, conflicts of interest, and other issues of accountability.S · Products and focus. The proposed assessment entity would have one primary product: periodic publication of assessments of the guidelines issued by public and private organizations.
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From page 214... ...
It might also produce assessments or commentaries on related items such as medical review criteria, commercial software products, software standards such as those promulgated by the American Society for Testing and Materials, and new graphic display techniques. Another information dissemination effort might be the production of occasional special publications or the sponsorship of conferences (with published proceedings)
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From page 215... ...
The assessment organization should have a user orientation that extends to a range of interested parties. Still, its assessments should be particularly attuned to everyday clinical practice and sensitive to the reliance of practitioners on their professional societies for guidance and support.
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From page 216... ...
Chapters 6 and 7 noted a number of outstanding technical and methodologic issues relating to cost-effectiveness analysis, weighing and combining evidence, consensus development and expert judgment. Clarifying the statistical aspects of, say, meta-analysis or effect sizes as they relate to amassing and interpreting scientific evidence is another.
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From page 217... ...
Some proposals for reform include provisions for clinical practice guidelines that would seem generally consistent with the committee's views on who should make judgments about what is worth covering under public or private health benefits plans. For example, one proposal would create a Health Standards Board to design a set of "uniform effective health benefits" that
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From page 218... ...
Some of the health care reform proposals that are described above and that are being widely discussed in the health policy literature and lay media envision sweeping changes in the nation's health care delivery and financing systems. These changes would certainly place guidelines in a framework of incentives for cost containment that is different from what currently exists.
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From page 219... ...
The danger in such proposals is that the potential contributions guidelines have to make in improving the quality of health care and health outcomes may be lost in a perception that guidelines serve only cost-containment purposes. The committee sees, therefore, both unprecedented opportunities for the clinical practice guidelines movement as well as exceptional challenges in the years ahead.
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