The federal government's Agency for Health Care Policy Research has designated 12 "evidence-based practice centers" in the U.S. and Canada to work on how to implement medical guidelines and evaluate technology.
The practice centers, with an annual budget of $3 million, and the new National Guideline Clearinghouse are intended to help physicians, health plans and providers apply the best scientific knowledge available to clinical decisionmaking.
"The power of the purse can stimulate reform in healthcare," AHCPR Administrator John M. Eisenberg, M.D., said at a Sept. 8 symposium sponsored by the Baxter Allegiance Foundation. "Our role as a science agency is to make sure the evidence is there upon which those guidelines can be written."
The National Guideline Clearinghouse is a joint project of the AHCPR, the American Medical Association and the American Association of Health Plans. It's supposed to make practice guidelines available to anyone who has a computer and modem. It should be on the World Wide Web by fall 1998.
The budget for the clearinghouse hasn't been determined while the agency negotiates with bidders.
"We'll have side-by-side analysis of strengths and weaknesses of each guideline so you can choose what's best for you," Eisenberg said.
In the past five years, the AHCPR produced 19 sets of clinical practice guidelines that have been widely used and adopted.
"Times have changed," said Douglas B. Kamerow, M.D., director of the AHCPR's Office of the Forum for Quality and Effectiveness in Health Care. "There are lots of guidelines out there now. You can't get away with putting a bunch of experts in a room and coming out with a guideline two hours later."
The amount of published research on these topics also has grown so voluminous that providers seeking to set up practice guidelines are overwhelmed by the literature search before they begin.
To streamline the process and reduce duplication, the 12 EPCs will be assigned specific topics, such as adult health, maternal health, geriatrics, rehabilitation, mental health, alternative care and preventive care. They will review critically all relevant scientific literature and write reports, which will be placed on the Web and printed as documents. These evidence reports are intended to provide a scientific foundation for private-sector providers to design their own strategies for improving quality.
Kamerow said it's not just physicians who need better data on evidence-based practices, it's anybody who's responsible for allocating resources or tracking utilization in healthcare.
The EPCs will not produce actual guidelines but will conduct meta-analysis of research and look at how to implement guidelines.
By the end of this month, the AHCPR will announce which centers will study which topics. Several hundred specific topics have been nominated. Those topics should be fairly narrow, Kamerow said, such as: How would you treat a certain heart disease in elderly people? They wouldn't focus on something like treatment of heart attacks. "That's too broad," he said. More to the point would be, "What medicines can you give after a heart attack to reduce morbidity and mortality, and what is the evidence for those?"
The 12 centers have five-year contracts to do the work (See chart). Thirty-three institutions submitted bids. Their proposals were evaluated and ranked by a nongovernmental panel of experts.
"We took the top 12," Kamerow said. "We were going to take fewer, but they were so strong, we took 12."
The problem of implementation is foremost on the AHCPR's agenda. Kamerow wants to find out how to take these evidence-based tools and put them into practice, "to close the gap between what we know and what we do."
"It's a good idea," said outcomes expert David B. Nash, M.D., associate dean for health policy at Jefferson Medical College in Philadelphia. "I wish the 12 centers all the luck in the world. I hope they'll be able to help us all learn the generic lessons of implementation, broadly applicable."
The AHCPR moved away from writing guidelines after it came under fire from Congress and its funding was threatened. Some people felt that guidelines shouldn't come from government agencies but should come from the healthcare professions and from multiple stakeholders.
The AHCPR is budgeted at $144.4 million in fiscal 1997. President Clinton requested $149 million for fiscal 1998.
"The technology of how to write a guideline has been fairly well perfected," Nash said. "The agency felt its new goal ought to be to concentrate on the next step, the implementation. Nobody knows how to do that."