Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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2 DEVELOPING CLINICAL PRACTICE GUIDELINES
2 DEVELOPING CLINICAL PRACTICE GUIDELINES
Pages 45-64
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From page 45... ...
This reality underscores the importance of the review and updating process noted in Chapter 1. More generally, the way clinical practice guidelines are developed can strongly affect their potential for effective use by practitioners, patients, and others.
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From page 46... ...
PLURALISM AND DIVERSITY IN GUIDELINES DEVELOPMENT Systematic efforts to develop clinical practice guidelines have grown dramatically in recent years. Professional societies, public agencies, health care institutions, and researchers have become appreciably more active and visible in the guidelines arena (Woolf, 1990b; Kosterlitz, 1991~; the field also has at least one regular newsletter, Report on Medical Guidelines and Outcomes Research (Robinson, 19911.
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From page 47... ...
are also increasingly involved in guidelines efforts. Overall, professional societies are generally seen as having taken the lead in organized efforts to develop practice guidelines, thereby serving as an important, perhaps key, 2 Readers interested in technical descriptions of current methods might examine the following: the AHCPR Forum manual developed to assist guidelines panels (Woolf, 1990a)
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From page 48... ...
together started a Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures.4 Work by this group on coronary artery bypass graft 3 Space does not permit a complete listing of all the topics on which these specialty societies have developed guidelines in the past decade or so. As noted earlier, the AMA is now tracking such efforts as are some commercial firms.
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From page 49... ...
The first is a collaboration between the AMA and 14 national medical specialty societies known as the Specialty Society Partnership. The second is the Practice Parameters Forum comprising "all national medical specialty and state medical societies interested in participating .
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From page 50... ...
Several nonphysician professional associations are also engaged in guidelines development and related activities. Since the late 1960s, the American Nurses Association has developed standards of nursing practice and universal practice guidelines in consultation with specialty nursing organizations (ANA, 1990~.5 The American Dental Association recently developed its first practice guideline on the general-initial dental examination; the group is not planning a guideline for 1992 but may return to the effort in 1993.
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From page 51... ...
defending against outside forces. The second objective may cover efforts to reduce malpractice and its associated costs, to encourage greater uniformity in health insurance coverage and utilization review criteria, and to counter conflicting guidelines developed by other specialty societies.
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From page 52... ...
Finally, some professional societies have tried to integrate concerns about quality with concerns about appropriate payment for physician services. For example, an explicit goal of the ACP Clinical Efficacy Assessment Project is to produce sound definitions of good medical practice that can contribute to a rational system of payment for medical care (White and Ball, 1990~.
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From page 53... ...
. Food and Drug Administration Perhaps the earliest government entry into an activity similar to guideline development came with the assignment to FDA of responsibilities for the assessment of drugs (1938)
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From page 54... ...
By and large, however, guideline development involves a literature search followed by a consensus recommendation by the panel or working group (Steven Teutsch, Centers for Disease Control, personal communication, 1991~. As examples of guidelines developed by CDC, those of the Immunizations Practices Advisory Committee are used by many state health organizations; they are published in the Mortality and Morbidity Weekly Report and as stand-alone documents Another CDC publication, The Prevention and Treatment of Complications of Diabetes Mellitus, comes in a version for primary care practitioners and a version for patients.
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From page 55... ...
In addition, the Forum is also to arrange for the development of "standards of quality, performance measures, and medical review criteria through which health care providers and other appropriate entities may assess or review the provision of health care and assure the quality of such care." AHCPR has recently awarded a contract to the American Medical Review Research Center to translate three sets of guideline on urinary incontinence, postsurgical pain management, and benign prostatic hypertrophyinto medical review criteria. Those criteria are to be applied by Medicare peer review organizations (PROs)
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From page 56... ...
By the end of the first, 12-month phase the contractors are expected to produce a sciencebased, pilot-tested, peer-reviewed guidelines document; at that point AHCPR will determine whether the original contractor should continue with the second phase and translate the guidelines into medical review criteria and standards of quality. For both phases (phase 1 in parentheses)
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From page 57... ...
These types of indicators, which have become one of the benchmark categories of medical review criteria, are discussed more fully in later sections of this chapter. More recently, HCFA has also supported guideline development as part of its contracts with Medicare PROB.
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From page 58... ...
utilization review efforts.~3 In keeping with the legislative emphasis on "local" (regional or state) peer review, and in the face of a dearth of accepted national guidelines, the PROs generally have had and have exercised considerable discretion to create, adopt, or adapt review criteria.
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From page 59... ...
For instance, in 1990, OTA released Preventive Health Services for Medicare Beneficiaries: Policy and Research Issues, which compiles recommendations published by other groups concerning such topics as periodic health examinations. It also cites assessments of preventive services (e.g., screening for breast cancer, for other types of diseases such as cervical cancer or glaucoma, and for abnormally high levels of cholesterol; vaccines against pneumococcal pneumonia and certain types of influenza)
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From page 60... ...
The original notion was that the AMCC and RAND would be responsible for conducting research to develop the criteria and for using them to evaluate cases at the individual medical centers. The AMA, through its Specialty Society Partnership and Practice Parameters Forum, would use the research results to facilitate the development and dissemination of practice guidelines.
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From page 61... ...
are best served by affecting clinical practice positively through provider education rather than through retrospective review and possible claims denial; national medical organizations are a leading and appropriate source of guidance; and physicians will more readily accept such guidance when it is developed and provided by their representative medical organizations than when it is provided by an insurer (Morris, 1987~.~6 BCBSA has also created the Technology Evaluation and Coverage program to provide proprietary information to Blue Cross and Blue Shield plans to use in making benefit coverage determinations. Another interesting initiative is that being developed in Minnesota by more than 50 health care institutions and other organizations (Borbas et al., 1990; Catherine Borbas, Healthcare Education and Research Foundation, personal communication, December 31, 1991~.
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From page 62... ...
In some cases, guideline developers can cite direct costs for such items as travel, printing, meeting expenses, consultants, and other line items.~7 Few organizations, however, can report costs for staff support, general overhead, i7 For example, the cost of developing appropriateness criteria, evidently counting staff time as well as other direct costs (including nominal honoraria to physician participants) but excluding related research activities, has been estimated at between $250,000 and $500,000 for each set of procedure-specific indicators.
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From page 63... ...
Public Health Service, personal communication, March 27, 1991~. John Ferguson, the director of OMAR, estimates that each consensus conference costs about $82,000 in direct costs, but that estimate does not include staff or volunteer participant time (John Ferguson, National Institutes of Health, personal communication, 1991~.
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From page 64... ...
64 GUIDELINES FOR CLINICAL PRACTICE of the guidelines that are produced are reflected especially in the methods used and in the costs; generally, costs for producing authoritative guidelines are higher than many experts originally anticipate, owing in large measure to the attention directed to a definitive review and analysis of the literature. This report now moves on to issues of implementation.
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