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INTRODUCTION AND BACKGROUND 21 work involves expanding the scope of knowledge rather than applying it. Of AHCPR's appropriation of nearly $100 million for fiscal year 1990, it planned to obligate around $2 million for the Forum's work on practice guidelines. (Some projects funded as research on outcomes will also involve the development of guidelines.) In any case, the agency's responsibilities for such guidelines reflect congressional recognition of the practical need for ways to translate knowledge into patient and practitioner decisions that improve the value received for the nation's health care spending. More generally, the creation of a practice guidelines function within AHCPR can be seen as part of a significant cultural shift, a move away from unexamined reliance on professional judgment toward more structured support and accountability for such judgment (Physician Payment Review Commission, 1989; Roper et al., 1988). Reflecting one element of this shift, guidelines are intended to assist practitioners and patients in making health care decisions; reflecting the second aspect, they are to serve as a foundation for instruments to evaluate practitioner and health care system performance. As the interest in practice guidelines has grown, so has scrutiny of existing guidelines and of processes for developing and using them (Brook, 1989; Eddy, 1987, 1988, 1990aâe, forthcoming (a,b); IOM, 1989, 1990; Leape, 1989, 1990; Physician Payment Review Commission, 1988a,b, 1989). This scrutiny leads to one clear conclusion: the systematic development, implementation, and evaluation of practice guidelines, based on rigorous clinical research and soundly generated professional consensus, have been progressing but also have serious limitations in method, scope, and substance. Concerns about these and other problems with practice guidelines contributed to the legislation creating AHCPR and the Forum. OVERVIEW OF PRACTICE GUIDELINES INITIATIVES Taken together, the public and private activities related to practice guidelines can be conceptualized, ideally, as having three basic stages: development, intervention, and evaluation. The second and third stages shouldâagain, ideallyâ involve feedback loops to the first stage to prompt the revision of guidelines when omissions, technical obsolescence, or other problems are identified. Guidelines are thus dynamic, not static. They reflect the interplay of scientific and technological progress, real-world organizational pressures, and changes in social values. To date, most government and other initiatives emphasize the first of the three stages, the development of practice guidelines. The intervention stage involves much more diffuse and less studied efforts to disseminate guidelines to target users and to encourage these users to actually apply the guidelines in making health care decisions. Only recently has much
