A Normative Analytic Framework for Development of Practice Guidelines for Specific Clinical Populations

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Abstract
Background. A central problem in practice guideline development is how to develop guidelines that appropriately account for variations in clinical populations and practice settings. Despite recognition of this problem, there is no formal mechanism for as sessing what the need is for flexibility in guidelines, or for deciding how to incorporate such flexibility into recommendations. Objective. This research sought to provide a formal basis to determine when clinical circumstances vary sufficiently that guideline recommendations should differ, how recommendations should be tailored for a specific clinical setting, and whether the benefit associated with such site-specific guidelines justifies the expense of their development. Results. The authors describe an approach for estimating the maximum health benefit that developers can obtain by eliminating uncertainty about differences in the patient populations and practice settings in which a guideline will be used. This estimate, the expected value of customization, provides a mechanism to evaluate the cost-effectiveness of the development of site-specific guidelines that account explicitly for variation in clinical circumstances. Application of this method to the development of screening guidelines for human immunodeficiency virus (HIV) infection indicates that the development of site-specific guidelines poten tially is cost-effective. Site-specific guidelines either improve, or leave unchanged, the efficiency of HIV screening; whether they increase or decrease total expenditures and health benefits depends on the choice of a cost-effectiveness threshold, and the clin ical problem. Conclusions. Development of guideline recommendations based on de cision models provides a normative approach for evaluating the need for and the cost-effectiveness of site-specific guidelines that have been tailored to specific prac tice settings. Such site-specific guidelines can improve substantially the expected health benefit and the economic efficiency of practice guidelines. Key words: practice guidelines; decision models; cost-effectiveness; site-specific guidelines. (Med Decis Making 1997;17:409-426)