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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 73 felt that a specialist user of a particular technology (for example, a cardiac surgeon who performs coronary artery bypass surgery) should never chair a group developing guidelines on the use of that technology. Others felt that exceptions to the general principle might sometimes be warranted. There was considerable agreement that a physician should chair the development of any clinical practice guidelines. Again, explicit attention to questions of bias is essential. Participation by affected groups in the process of guidelines development can be achieved in several ways. The strongest form of participation is membership on the panel charged with developing guidelines, but the benefits of this approach have to be balanced against the practical management problems created by too large a panel. Participation may also be achieved through mechanisms other than the panel âfor example, public hearings, circulation of draft guidelines for review and comment by a wide variety of groups, and contracts with particular interests for specific analyses. Focus groups and pretests may uncover confusing language or highlight the "hassle factor" associated with draft guidelines and allow practitioners or patients to suggest more acceptable alternatives. Different types of guidelines are likely to require different mechanisms for participation, and the benefits of participation need to be balanced against resource limitations and other constraints. Therefore, this report stresses the principle and value of participation rather than the specific vehicles. Creativity and experimentation should, in fact, be encouraged. SCHEDULED REVIEW Clinical evidence and judgment are not static. Therefore, guidelines should designate a review date to determine whether they should be updated or, potentially, withdrawn. In a clinical area where technologies are changing rapidly and new research findings can be expected to accumulate quickly, a relatively short timetable may be appropriate. More stable clinical areas may permit a longer period before scheduled review. In every case, however, a guideline should contain a specific review date or time frame for review (for example, within three years of initial publication). The greater the amount of change in a clinical area, the more the revision process will resemble the initial development process in scope, cost, and intensity. Follow-up on review schedules is part of the implementation process (see Chapter 4) as is determination of whether review is needed before the scheduled date. Unscheduled revisions may be prompted by major new clinical evidence or by emerging or disintegrating professional consensus. To oversee both scheduled and unscheduled reviews, an organization responsible for the development of multiple sets of guidelines should subject
