In an effort to improve the quality, appropriateness, and effectiveness of health care services and access to such services, the Congress established the Agency for Health Care Policy and Research (AHCPR) in December 1989. Many of the functions assigned to the AHCPR had been under the purview of the National Center for Health Services Research. However, one important new function was given to the Agency: its administrator was to arrange for the development of clinical practice guidelines.

Practice guidelines for medicine are not new. For many years, some medical specialty societies have published forms of guidance as educational tools. Physicians affiliated with individual hospitals or hospital groups have also initiated guidelines, as have insurance companies and peer review organizations that exert influence on medical practice through payment or care-review determinations.

In response to your request that we examine methods for the development of guidelines, we reviewed the experience of medical specialty societies that have developed them. We contacted 35 societies that were identified by the American Medical Association or the Council of Medical Specialty Societies as possessing or developing guidelines and inquired of each whether their guidelines met the following definition:

"guidance-by whatever name—that aids practicing physicians and others in the medical community (and consumers, if included) in day-to-day decisions by describing the degree of appropriateness and the relative effectiveness of alternate approaches to detecting, diagnosing, and/or managing selected health conditions."

Twenty-seven societies responded that they possessed or were developing such guidelines, and they agreed to participate in our study. (Appendix IV lists the organizations that provided information to us.) Our interviews with representatives from these societies were structured to obtain information on

why guidelines were developed,

what kinds of guidelines were developed (scope, types of recommendations, types of products),

⚫ the methodology used to develop guidelines,

who was involved in developing guidelines,

how guidelines were disseminated,

what provisions existed for updating guidelines, and

how much effort was required to produce guidelines.

The society representatives' responses to these questions are provided in appendix II. Even a cursory review of those responses is sufficient to establish that there is no uniformity when it comes to developing practice guidelines. Medical societies vary in

the reasons why they develop guidelines (to improve quality, to guard against intrusions by others);

the types of guidelines they produce (ranging from a 3-page quality assessment tool to a book with recommendations on whether, when, and how to treat a host of medical conditions);

⚫ the focus of their guidelines (procedures, diagnoses);

the persons they involve in development (most use physician members, but some include nonmembers or seek the advice of nonphysicians); and

even

the words they use to refer to guidelines (“practice parameters," "clinical policies," "preferred practice patterns”).

In the course of our interviews, we also asked society representatives for their views on what characteristics guidelines should have, how guideline development should proceed, and how to maximize compliance with the guidelines and evaluate their impact. Appendix III presents the responses of the representatives on these issues, which are best characterized as varied.