On-line clearinghouse to serve consumers, providers
Care guidelines to be evidence-based, updated
This month our guest is John M. Eisenberg, MD, administrator of the Agency for Health Care Policy and Research (AHCPR). He assumed leadership in early 1997, just as the agency accepted designation as Health and Human Services' lead group for health care quality improvement issues.
No stranger to the quality improvement scene, Eisenberg was a founding commissioner of the Congressional Physician Payment Review Commission. For the last two years of his 1986-1995 tenure, he chaired the body.
As a clinician, Eisenberg chaired the Department of Medicine at Georgetown University Medical Center. Prior to that, he was chief of the General Internal Medicine division at the University of Pennsylvania. He has been elected a master of the American College of Physicians.
Eisenberg also received a master's degree in business administration from the Wharton School. He has published more than 200 articles and book chapters on topics such as physicians' practices, test use and efficacy, medical education, and clinical economics.
Joining Eisenberg is Jean Slutsky, project officer for the National Guidelines Clearinghouse Project. Slutsky manages the daily operations of keeping the massive process on schedule.
Q. AHCPR is creating a Web site that will serve as the premier, one-stop source for clinical practice guidelines. Will this include every clinical practice guideline? And could you ballpark how many that will be?
A. We have not really set a specific number. The idea is to include guidelines that are based on evidence and reflect a scientific approach to clinical decision making. When planning this project, we assumed there would be thousands of such guidelines that might be candidates for inclusion in the National Guideline Clearinghouse (NGC).
Q. Will any areas be excluded?
A. No topic area covered by a clinical practice guideline will be excluded. We are hoping this will be a very broad-based clearinghouse of clinical practice guidelines so a variety of users will find it helpful.
Users of the NGC might include primary care physicians, specialty physicians, other health professionals - nurse practitioners, physicians assistants, dentists, and others - and patients or consumers (if you think of people before they become patients as consumers).
The needs of these clearinghouse users are going to be different, so we will indicate who is the intended audience for each guideline. Sometimes guideline developers will even structure a different guideline on the same topic for different groups.
Q. Could you elaborate on the criteria you're using for inclusion of guidelines?
A. We want to be sure the guideline was developed using science-based evidence. That is the most important characteristic. We want to make sure that the evidence is verifiable. This usually will require that the underlying source has been published in peer-reviewed journals and has been applied appropriately. We need to be sure that the scientific evidence is solid and verifiable, and that corroborating documentation is available.
Another criterion is that the guideline include information or strategies that can help to guide decision makers. We do not want them to be just interesting reviews of the literature. The two key words are evidence and decision - guidelines that are evidence-based and that guide decisions. They need to be available in English, and they must have been developed, revised, or updated within the last five years.
(Slutsky) The definition of a clinical practice guideline that the NGC is using is the one developed by the Institute of Medicine. "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."1
(Eisenberg) There are guidelines that groups have written that are not based in science, or at least you cannot tell if they are based in science. They may be based on what a group of smart people has suggested after sitting around a room talking about what ought to be a good way to take care of patients.
We want to use the knowledge and experience of experts, but we want to be sure that when the experts came to their conclusions, they based their thinking on science and not habit, on evidence and not custom. Therefore, having expert input is an attribute we admire in guidelines, but it is not going to be enough by itself to get a guideline into the NGC. It has to be evidence-based.
Q. Will the material show up as full text or summaries?
A. There will be a side-by-side comparison of guidelines on similar topics, much like a spreadsheet, that will show information such as how they were put together, the intended audience, and the group that developed them. Then there will be another set of side-by-side comparisons that deals with the key issues. This project will not be one just to scan guidelines and put them on the Web. That would not be much of a service.
We will identify the key issues of a particular question and then develop a side-by-side comparison of the guidelines in terms of how they address those particular issues. For example, for a screening test, how often should it be done? At what age should it be started? Different guidelines may differ on those characteristics, and this will enable the user of the NGC to see what the different recommendations are.
There is not just one way to practice medicine or to address the health needs of the public. You could think of this like a road map - there may be several ways to get from one place to another, and the traveler needs good information about each route in order to choose the best one for his or her own individual circumstances.
In addition to this side-by-side comparison, we will make it possible for users to get the full text through the NGC or through a hot link to the Web site of the organization that wrote the guideline. In some instances, when there is a charge for the guideline, we will let the user know how to get in touch with the organization that can make it available.
Q. Will there be additional features on the site?
A. There will be an electronic forum where interested groups can talk about different aspects of guideline development, implementation or use. We will also have annotated bibliographies on different aspects of guideline development methodologies and implementation.
Q. In downloading the materials from your site, is it going to be considered public domain materials or will users have to get copyright permission?
A. There will be instances in which people can get access to the guideline without having to pay, or in which copyright approval can be obtained so the user will not to have to hot link to that organization. But if there are restrictions with either copyright or ownership, we will honor them, and they will be clearly stated. People will be referred to the guideline developer so they can abide by the copyright or the commercial interest of the developer.
Q. Could you name a few of the organizations who are supplying guidelines for the site?
A. Keep in mind that we are still developing the site. However, we have had informal conversations with many guideline developers, and we are confident there will be a fairly universal contribution of guidelines.
Q. Who's doing the technical work of creating the site?
A. (Slutsky) A nonprofit health services research organization called ECRI. They are located in Plymouth Meeting, PA.
(Eisenberg) It is an organization with an excellent reputation for being scientific and professional. We sponsored a national competition, which Jean (Slutsky) spearheaded, and we had some of the best organizations in the country apply to manage the NGC.
Q. What features are already on AHCPR's Web site that QI/TQM's readers could check right away for benchmarking and other data needs?
A. (Slutsky) AHCPR's home page contains a lot of information that might be of use to your readers, including the guidelines we have sponsored, as well as information on quality improvement, outcomes research, and related topics.
Q. Stepping back to look at the larger perspective, what do you see as AHCPR's role in helping maintain health care quality?
A. First, it is important to emphasize that there is plenty of evidence that all of us who are part of the country's health care system need to do more where quality of care is concerned. We can do better!
We can close the gaps between what we know how to do and what we do in health care today. That means we can improve, not just maintain quality.
If this agency does not sponsor and conduct research on the cutting edge of quality improvement and quality measurement, we are convinced that it will not get done. This is an essential function we play, one that is in the public's clear interest.
We try to develop new ways of measuring quality and improving quality based on knowledge and information that we can help generate. That ranges all the way from developing measures of health care outcomes to use in quality assessment to looking at performance measures of the process or structure of care. We are funding a variety of projects that deal with this spectrum of research.
Second, it is important that we take information about measuring and improving quality, and develop tools that will help people to apply it. The NCG represents one type of tool, but there are many others ways of improving care.
We also developed a measure of consumer satisfaction - called the Consumer Assessment of Health Plans - that Health Care Financing Administration and Office of Personnel Management recently announced they will be adopting, and we believe others will be adopting this new tool, as well.
The third way we can contribute is through dissemination, which the NGC will help us to do. It is important to get the results of research to those who can use it, not just to publish the results in a journal.
The final role we hope to play is evaluation. In the spirit of total quality improvement, we believe we ought to be doing the same thing for ourselves that we ask everybody else to do. So, we evaluate the impact of our tools and these dissemination projects to see how well we have done and to improve the information available for improving quality of care.
In addition, we collaborate with other federal agencies like National Institutes of Health and Centers for Disease Control and Prevention. We collaborate with the private sector, as well; for example, we collaborate with the National Committee for Quality Assurance, and a variety of other organizations.
[The National Guideline Clearinghouse is expected to be on-line at the end of this year. Meanwhile, visit AHCPR's existing site on the World Wide Web: http://www.ahcpr.gov. Or, contact them at P.O. Box 8547, Silver Spring, MD 20907-8547. Telephone: (800) 358-9295.]
1. Field MJ, Lohr KN, eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990. n