American College of Physicians: Internal Medicine — Doctors for Adults ®


AHCPR revamps process to build a better guideline

From the March 1995 ACP Observer, copyright 1995 by the American College of Physicians.

WASHINGTON--Facing up to criticism from health care providers and policy makers that its clinical practice guidelines have been too broad and off-target to be useful, the federal Agency for Health Care Policy and Research (AHCPR) is streamlining its operations, refocusing its priorities and even rethinking its role as a sponsor of guidelines.

The 5-year-old agency, created by Congress to fund and conduct research to improve the quality of health care in America, is in the middle of a soul-searching process. Leading that effort are a new administrator, Clifton R. Gaus, ScD, and new guideline-development director, Douglas B. Kamerow, MD, MPH, who comes to the AHCPR from the U.S. Preventive Services Task Force, another guideline-writing agency.

"We can't continue to do business as we have and continue to be on the cutting edge," Dr. Gaus told a meeting this winter of the agency's national advisory council. "Part of our thinking is that we need to build into the research from the beginning how [the results of that research] can be disseminated, how it can be useful."

The job of writing clinical practice guidelines to bridge the gap between what doctors, nurses and other health care providers know and what they do was specifically assigned to AHCPR by Congress at a time when numerous specialty societies, hospitals and utilization review companies were distributing guidelines. Few of those guidelines were considered to be based in science; some were even thought to be dangerous to patients. AHCPR's job was to set a standard for higher quality guidelines by developing a methodology that stressed collecting, distilling and disseminating all the scientific evidence and expert opinion on best practices.

Even the agency's detractors concede that AHCPR, with its high profile and $160 million budget (accounting for one-third of all federal spending on health services research), has been successful in elevating the standards by which guidelines are developed today. The question is, therefore, does the federal government still need to be in the business of telling health providers how to practice medicine, or is that a job better left to private health care practitioners, systems and institutions? President Bill Clinton's fiscal 1996 budget request, submitted to Congress on Feb. 6, calls for increasing the agency's budget by $31 million, or 19%, over current fiscal year funding. The budget for the agency's Medical Treatment Effectiveness Program, which includes guidelines, would be increased 9%, to $88 million, under the president's proposal.

Each of AHCPR's guidelines has cost the agency between $500,000 and $750,000 to develop, another $310,000 to print, and between $310,000 and $350,000 to market, according to AHCPR staff. The agency has released 15 guidelines to date. Aside from a handful of anecdotes relating to particular hospitals or HMOs, there is little evidence the recommendations in AHCPR guidelines have made any significant difference in how medical care is provided in America.

That explains why, Dr. Kamerow said, the agency will now be devoting more time and effort to making the guidelines that bear its logo more user-friendly. As he told the national advisory council, the guidelines "are useless until somebody uses them."

He outlined some of the changes in the agency's guideline development process that should take effect later this year:

  • Focus. Improving prioritization and narrowing the topics so the guidelines are truly focusing on areas of health care where there is a gap between what clinicians know and what they do. "We don't need to be writing textbooks," Dr. Kamerow said.
  • Speed. Reducing the time it takes to produce each guideline and standardizing the methodology followed to create them by setting up standing multidisciplinary panels, whose expertise in evaluating scientific evidence will be augmented by topic experts. In the past, each guideline has been developed by a new panel, and getting each panel up to speed takes a great deal of time and money, Dr. Kamerow said. The new standing panels will be backed up with staff from three or four non-profit research centers, mostly at universities, whose work will be funded by AHCPR contracts.
  • Distribution. Revamping the way guideline recommendations are published. "We are not at all convinced that the four books (the 100-plus page guideline book, the quick reference guide for clinicians, the patient guide and a technical report) are the best way" to get the recommendations out to doctors and other users, Dr. Kamerow said. "Would it be better to have something that looks like a wall poster or a plastic card or a videotape?"

In the future, Dr. Kamerow envisions AHCPR devoting less time to guideline production and more of its efforts to evaluating other organizations' guidelines, testing them and keeping track of them, perhaps through some sort of a national clearinghouse.

"Maybe we'll be out of the guideline business totally, ultimately," he said. But for now, he said, "part of our job [will be] to do a few guidelines along the way. The ones we want to do are the ones where there are a lot of different players out there and it is unlikely they could come together and produce something unified."

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