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Some stated that guidelines should always be definitive, whereas others indicated that guidelines should reflect uncertainty when it is appropriate. Some suggested disclaimers to avoid adverse legal consequences,

whereas others believed disclaimers were unnecessary. • While a little more than half of the spokespersons reported that their

society members favored guidelines, others mentioned the reservations, wariness, and resignation of some members.

The variability evidenced both in how guideline development has proceeded in the past and in the opinions about how it should proceed in the future means that we can present no behaviors as ideal for adoption in guideline development efforts. Furthermore, the absence of evaluative studies either on the ways in which medical practice guidelines have been developed or on the impacts of guidelines limits our ability to make recommendations on the most efficient or effective mechanisms for guideline development or the best features of completed guidelines. What we can say is that the Agency's position is a challenging one in that

it will be conducting its work in an area where many of the interested parties (medical specialty societies) have already adopted different approaches; and the range of opinions about how guideline development should proceed will result in opposition by some physicians to any approach the Agency adopts.

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We conducted our interviews in the winter of 1990 and performed our work in accordance with generally accepted government auditing standards. Because our work focused on the activities of medical specialty societies and did not attempt to evaluate how the AHCPR has developed practice guidelines, we have not sent a draft of this report to the Agency for its comments.

As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days after the date of the report. At that time, we will send copies to the Department of Health and Human Services, the Agency for Health Care Policy and Research, and other interested parties upon request.

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