Guidelines for Clinical Practice -- Copyright -- Acknowledgments -- Contents -- Guidelines for Clinical Practice -- Summary -- WHAT ARE PRACTICE GUIDELINES? -- WHY ARE POLICY MAKERS INTERESTED IN GUIDELINES? -- GENERAL STRENGTHS AND WEAKNESSES OF CURRENT PRACTICE GUIDELINES ACTIVITIES -- What Are the Strong Points of Current Efforts? -- What Are the Limitations of Current Efforts? -- IMPROVING THE DEVELOPMENT OF GUIDELINES -- Building a Compelling Case for Recommendations -- Procedural and Methodological Issues Needing Particular Attention -- At the Interface Between Development and Use -- Local Adaptation of Guidelines -- Inconsistent Guidelines -- Formatting and Disseminating Guidelines -- Going Further? Defining Cost-Effective and Minimum Levels of Care -- Doing More? Guidelines for Informed Patient Decision making -- ENSURING THE USE OF GOOD GUIDELINES -- Quality Assurance and Improvement -- Cost Management -- Risk Management and Medical Liability -- Information and Decision Support Systems -- A CRITICAL NEED: MEANS TO ASSESS THE SOUNDNESS OF GUIDELINES -- Assessment Instrument -- Assessment Organization -- RESEARCH AGENDA -- FINAL NOTE: GUIDELINES AND HEALTH CARE REFORM -- 1 Introduction -- PURPOSE OF THE REPORT -- WHAT ARE PRACTICE GUIDELINES? -- Definitions of Key Terms -- Desirable Attributes of Guidelines -- Elements of Analysis -- State of the Evidence -- Inconsistent or Conflicting Guidelines -- Types of Guidelines -- WHY ARE POLICY MAKERS INTERESTED IN GUIDELINES? -- WHO USES GUIDELINES AND FOR WHAT? -- BASIC PROPOSITIONS -- REPORT ORGANIZATION -- SUMMARY -- 2 Developing Clinical Practice Guidelines -- PLURALISM AND DIVERSITY IN GUIDELINES DEVELOPMENT -- PROFESSIONAL SOCIETIES AND RELATED ENTITIES -- How Are Professional Societies Involved? -- Why Are Professional Societies Involved? -- PUBLIC AGENCIES -- U.S. Public Health Service.

Food and Drug Administration -- National Institutes of Health -- Centers for Disease Control -- Agency for Health Care Policy and Research -- Other Public Agencies -- Health Care Financing Administration -- U.S. Preventive Services Task Force -- Congressional Office of Technology Assessment -- PRIVATE RESEARCH, PAYER, PROVIDER, AND OTHER GROUPS -- COSTS OF GUIDELINES DEVELOPMENT -- SUMMARY -- 3 Implementing Guidelines: Overview and Illustrative Cases -- GUIDELINES AND THE REAL WORLD -- CASE STUDIES -- Case Study 1: Small Internal Medicine Practice -- Case Study 2: Managed Care Organization -- Case Study 3: Academic Medical Center Hospital -- Case Study 4: Community Hospital -- Case Study 5: Nursing Home and Hospice -- Case Study 6: Patient -- GENERAL ISSUES IN IMPLEMENTATION -- Factors Influencing the Effective Use of Guidelines -- Strategies to Encourage Effective Use of Guidelines -- SUMMARY -- 4 Implementing Guidelines: Conditions and Strategies -- CONTEXT, PHILOSOPHIES, AND STRATEGIES -- EDUCATION -- INFORMATION AND DECISION SUPPORT SYSTEMS -- Current Systems -- Promising Developments -- Access to Information -- Decision Support -- Outcomes and Guidelines Revision -- Integrating Financial and Clinical Management Systems -- Directions for Information Systems -- SUMMARY -- 5 Implementation: Quality, Cost, and Risk Management -- QUALITY ASSURANCE AND IMPROVEMENT -- Basic Concepts and Propositions -- Continuous Quality Improvement -- Medical Review Criteria -- General Issues in the Use of Medical Review Criteria -- Selected Illustrative Activities Related to Medical Review Criteria -- Directions for Quality Assurance Strategies -- COST MANAGEMENT -- Coverage Policy and Administration -- Types of Coverage Decisions -- Medical Review Criteria and Managing Benefit Costs -- Concerns about Tort Liability.

Credentialing, Selective Contracting, and Related Strategies -- Other Economic Incentives -- Directions for Cost Management -- RISK MANAGEMENT, MEDICAL LIABILITY, AND PRACTICE GUIDELINES -- Risk Management -- Medical Malpractice -- Malpractice Defined -- According Guidelines Greater Weight in Determining the Standard of Care -- Directions for Risk Management and Liability Standards -- SUMMARY -- 6 The Inescapable Complexity of Decision making: Ethics, Costs, and Informed Choices -- AN ETHICAL CONTEXT -- Ethical Obligations of Individuals -- Ethical Obligations of Collective Social Systems -- GUIDELINES, COSTS, AND DECISIONS -- Why Present Information About Costs? -- Should Developers of Guidelines Go Further? -- Explicit Judgments about Cost-Effectiveness -- A Modest Proposal -- THE PATIENT AS DECISION MAKER: WHAT IS INFORMED CHOICE? -- Informed Consent -- Patient Preferences -- Information, Preferences, and Policy: The Need for Guidelines on Patient Information and Informed Consent -- Provision of Information under Condition-Specific or Treatment-Specific Guidelines -- General Guidelines for Patient Information -- THE PHYSICIAN AS DECISION MAKER: WHAT CARE IS REQUIRED? -- More Definitions -- Practical and Policy Issues -- What Should Developers of Guidelines Do? -- SUMMARY -- 7 Evolution in Procedures and Methods for Developing Practice Guidelines -- GENERAL STRUCTURES AND PROCEDURES -- Learning Lessons: The Agency for Health Care Policy and Research -- Building a Formal Program: The Clinical Efficacy Assessment Program -- Improving Consensus Development: The National Institutes of Health -- Interorganizational Cooperation: Medical Societies and Others -- PERSISTENT QUESTIONS FOR THE DEVELOPMENT PROCESS -- Participation in the Process -- Creating Guidelines Panels and Selecting Panel Members -- Selecting Reviewers of Draft Guidelines.

Updating Existing Guidelines -- AREAS FOR METHODS RESEARCH AND DEVELOPMENT -- Topic Selection -- Expert Panel Processes -- Evaluating Scientific Evidence -- Patient Outcomes -- Patient Preferences -- Conflicting or Inconsistent Guidelines -- ISSUES AT THE INTERFACE OF DEVELOPMENT AND IMPLEMENTATION -- Local Adaptation -- Reasons for Local Adaptation -- Processes for Local Adaptation -- The Standing of "Adapted" Guidelines -- Formatting and Dissemination -- Evaluating Impact -- SUMMARY -- 8 A Framework for the Future -- WORKING ASSUMPTIONS AND PRINCIPLES -- GENERAL STRENGTHS AND WEAKNESSES OF CURRENT PRACTICE GUIDELINES ACTIVITIES -- What Are the Strong Points of Current Efforts? -- What Are the Limitations of Current Efforts? -- IMPROVING THE DEVELOPMENT OF GUIDELINES -- Building a Compelling Case for Recommendations -- Procedural and Methodological Issues Needing Particular Attention -- At the Interface Between Development and Use -- Local Adaptation of Guidelines -- Inconsistent Guidelines -- Formatting and Disseminating Guidelines -- Going Further? Defining Cost-Effective and Minimum Levels of Care -- Doing More? Guidelines for Informed Patient Decision making -- ENSURING THE USE OF GOOD GUIDELINES -- Quality Assurance and Improvement -- Cost Management -- Risk Management and Medical Liability -- Information and Decision Support Systems -- A CRITICAL NEED: MEANS TO ASSESS THE SOUNDNESS OF GUIDELINES -- Assessment Instrument -- Assessment Organization -- Is an Assessment Organization Needed? -- Is an Assessment Organization Feasible? -- Is There a Reasonable Probability That These Conditions Will Prevail? -- RESEARCH AGENDA -- FINAL NOTE: GUIDELINES AND HEALTH CARE REFORM -- References -- APPENDIXES -- A Examples of Clinical Practice Guidelines and Related Materials -- FORMATTING GUIDELINES -- Free Text -- Formalized Presentations -- Algorithms.

Flowcharts and Similar Formats -- Proposed Standards -- Computer-based Formats -- Example 1 -- Screening for Diminished Visual Acuity -- Burden of Suffering -- Efficacy of Screening Tests -- Effectiveness of Early Detection -- Recommendations of Others -- Discussion -- Clinical Intervention -- REFERENCES -- Example 2 -- VACCINATION DURING PREGNANCY -- Example 3 -- Example 4 -- Example 5 -- PROBLEMS OF INTERPRETATION IN SYMPTOMATIC PATIENTS -- PATIENTS WITH VAGUE, UNSUBSTANTIATED ILLNESS -- Example 6 -- RESULTS -- INDICATIONS AND RATINGS -- Example 7 -- Percutaneous Transluminal Coronary Angioplasty -- Example 8 -- 1 Introduction -- 2 Results of a trial of labour -- 3 Risks of caesarean section -- 3.1 Risks to the mother -- 3.2 Risks to the baby -- 4 Factors to consider in the decision about a trial of labour -- 4.1 More than one previous caesarean section -- 4.2 Reason for the primary caesarean section -- 4.3 Previous vaginal delivery -- 4.4 Type of previous incision in the uterus -- 4.5 Gestational age at previous caesarean section -- 4.6 Integrity of the scar -- 5 Care during a trial of labour -- 5.1 Use of oxytocics -- 5.2 Regional analgesia and anaesthesia -- 5.3 Manual exploration of the uterus -- 6 Rupture of the scarred uterus in pregnancy and labour -- 7 Gap between evidence and practice -- 8 Conclusions -- Example 9 -- Example 10 -- SCREEN FOR WORSENING METABOLIC ACIDOSIS -- Example 11 -- ESTROGENS AND ORAL CONTRACEPTIVES -- Example 12 -- Example 13 -- Example 14 -- Example 15 -- Example 16 -- Summary -- B A Provisional Instrument for Assessing Clinical Practice Guidelines -- PURPOSES OF THE ASSESSMENT INSTRUMENT -- DEVELOPMENT PROCESS -- Initial Reviews -- Final Reviews -- IMPORTANT FEATURES OF THE PROVISIONAL ASSESSMENT INSTRUMENT -- Attributes of Practice Guidelines -- Types of Attributes.

Implicit Weight Accorded to Different Attributes.