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SUMMARY 2 guidelines development, whether such development is supported directly by the Forum or is undertaken independently by medical societies and other organizations. The committee believes that the AHCPR initiative, taken as a whole, has real potential to advance the state of the art for practice guidelines, strengthen the knowledge base for health care practice, and, hence, improve the appropriateness and effectiveness of health care. One objective of this report is to encourage realistic expectations about this potential by building a broader understanding of the difficult but important steps needed to move toward the goals for practice guidelines stated in P.L. 101-239, or, as it is also called, the Omnibus Budget Reconciliation Act of 1989 (OBRA 89). CONTEXT The committee began its work with an understanding that the legislation establishing AHCPR is one consequence of accumulated public and private frustrations about the perceived health and economic consequences of inappropriate medical care. These frustrations and perceptions stem from many sources including ceaselessly escalating health care costs, wide variations in medical practice patterns, evidence that some health services are of little or no value, and claims that various kinds of financial, educational, and organizational incentives can reduce inappropriate utilization. The combination of high expenditures and doubts about the value of that spending explains policymakers' interest in improving the scope and application of knowledge about what works and what does not work in medical careâand at what price. AHCPR is supporting an extensive agenda of outcomes and effectiveness research. In fact, the major part of the agency's work involves expanding the scope of knowledge rather than applying it. Of AHCPR's appropriation of nearly $100 million for fiscal year 1990, it planned to obligate around $2 million for the Forum's work on practice guidelines, compared with more than $30 million for outcomes research. Still, the agency's responsibilities for practice guidelines reflect congressional recognition of the practical need for ways to translate knowledge into patient and practitioner decisions that improve the value the nation receives for its health care spending. More generally, the creation of a practice guidelines function within AHCPR can be seen as part of a significant cultural shift, a move away from unexamined reliance on professional judgment toward more structured support and accountability for such judgment. Reflecting the first element of this shift, guidelines are intended to assist practitioners and patients in making health care decisions; reflecting the second aspect, they are to serve
