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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 76 lie in the realm of aspiration rather than attainment. Second, a balance needs to be maintained between an ideal process and a feasible one. For example, this committee, and others, could design a very meticulous process to take into account the views of all interested groups. At some level, that process would consume more resourcesâin time, professional input, and moneyâthan the outputs would warrant. That is, it would be too slow, too cumbersome to administer, and too costly to meet the needs of providers, third-party payers, or patients. It undoubtedly would not conform to the congressional deadlines of OBRA 89. The third point to stress is that guidelines development must be an evolutionary process, especially at the national (or federal) level. There is no proven "right way" to conduct this endeavor, even if there clearly are some "better ways." Guidelines that satisfactorily reflect the eight attributes proposed here may not be products of an ideal process, but in the committee's view they will be defensible. Two other themes should be reiterated: the need for credibility among practitioners, patients, payers, and policymakers, and the need for accountability. The entire practice guidelines enterprise will not fulfill its promise (and certainly the federal program will not) if the products lack solid scientific grounding and widespread understanding and support from the provider and patient communities. The significance accorded such attributes as validity and reliability, clarity, multidisciplinary approach, and documentation reflects the committee's concerns with these needs. Although in the first instance the themes of credibility and accountability apply to the procedures followed in guidelines development, they also carry through to the procedures of implementation and evaluation, which are the subjects of the next chapter. REFERENCES American College of Physicians. Clinical Efficacy Assessment Project: Procedural Manual. Philadelphia, Pa.: 1986. American Medical Association. attributes to Guide the Development of Practice Parameters. Chicago, Ill.: American Medical Association, 1990a. American Medical Association. Preliminary Worksheet for the Evaluation of Practice Parameters. Draft of ad hoc review panel. Chicago, Illinois, May 1990b. Canadian Task Force on the Periodic Health Examination. Canadian Medical Association Journal 121:1193-1254, 1979. Battista, R., and Fletcher, S. Making Recommendations on Preventive Practices: Methodological Issues. American Journal of Preventive Medicine 4:53-67, 1988 (Supplement). Brock, D., and Wartman, S. When Competent Patients Make Irrational Choices. New England Journal of Medicine 322:1595-1599, 1990. Chassin, Mark. Presentation to the IOM Committee to Advise the Public Health Service on Practice Guidelines. Washington, D.C., April 2, 1990. Eddy, D. Comparing Benefits and Harms: The Balance Sheet. Journal of the American Medical Association 263:2493-2505, 1990a.
ATTRIBUTES OF GOOD PRACTICE GUIDELINES 77 Eddy, D. Guidelines for Policy Statements: The Explicit Approach. Journal of the American Medical Association 263:2239-2240, 1990b. Eddy, D. Practice Policies--Guidelines for Methods. Journal of the American Medical Association 263:1839-1841, 1990c. Eddy, D. Practice Policies--What Are They? Journal of the American Medical Association 263:877-880, 1990d. Eddy, D. Practice Policies--Where Do They Come From? Journal of the American Medical Association 263:1265-1275, 1990e. Eddy, D. Designing a Practice Policy: Standards, Guidelines, and Options. Journal of the American Medical Association, forthcoming (a). Eddy, D. A Manual for Assessing Health Practices and Designing Practice Policies. American College of Physicians, forthcoming (b). Eddy, D., and Billings, J. The Quality of Medical Evidence and Medical Practice. Paper prepared for the National Leadership Commission on Health, Washington, D.C., 1988. Fink, A., Kosecoff, J., Chassin, M., et al. Consensus Methods: Characteristics and Guidelines for Use. American Journal of Public Health 74:979-983, 1984. Frankel, S. Hello, Mr. Chips: PCs Learn English. Washington Post, April 29, 1990, p. D3. Gottlieb, L. Margolis, C., and Schoenbaum, S. Clinical Practice Guidelines at an HMO: Development and Implementation in a Quality Improvement Model. Quality Review Bulletin 16:80-86, 1990. Institute of Medicine. Effects of Clinical Evaluation on the Diffusion of Medical Technology. Chapter 4 in Assessing Medical Technologies. Washington, D.C.: National Academy Press, 1985. Institute of Medicine. Acute Myocardial Infarction: Setting Priorities for Effectiveness Research. Washington, D.C.: National Academy Press, 1990a. Institute of Medicine. Breast Cancer: Setting Priorities for Effectiveness Research. Washington, D.C.: National Academy Press, 1990b. Institute of Medicine. Hip Fracture: Setting Priorities for Effectiveness Research. Washington, D.C.: National Academy Press, 1990c. Institute of Medicine. Medicare: A Strategy for Quality Assurance, Lohr, K., ed. Washington, D.C.: National Academy Press, 1990d. Institute of Medicine. National Priorities for the Assessment of Clinical Conditions and Medical Technologies, Lara, M., and Goodman, C., eds. Washington, D.C.: National Academy Press, 1990e. Institute of Medicine. Workshop to Improve Group Judgment for Medical Practice and Technology Assessment, Washington, D.C., May 15-16, 1990f. Lomas, J. Words Without Action? The Production, Dissemination and Impact of Consensus Recommendations. Draft paper (dated May 1990) prepared for the Annual Review of Public Health, Vol. 12, Omenn, G., ed. Palo Alto, Calif., forthcoming. Mulley, A. Presentation to the Workshop to Improve Group Judgment for Medical Practice and Technology Assessment, Washington, D.C., May 15, 1990. National Research Council. Improving Risk Communication. Washington, D.C.: National Academy Press, 1989. Park, R., Fink, A., Brook, R., et al. Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures. R-3280-CWF/HF/PMT/RWJ. Santa Monica, Calif.: The RAND Corporation, 1986. See also the same authors and same title in the American Journal of Public Health 76:766-772, 1986. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore, Md.: Williams & Wilkins, 1989.
