Development of the AHCPR-Sponsored Heart Failure Guideline: Methodologic and Procedural Issues

Abstract

RAND, a nonprofit research and policy organization, served as contractor for the Agency for Health Care Policy and Research (AHCPR)-sponsored guideline on the management of patients with heart failure due to left-ventricular systolic dysfunction. At meetings of the 16-member panel, discussions concerning practice recommendations were held until a consensus was reached. A draft algorithm was the key tool, serving as a starting point for panel discussion. The algorithm was revised after almost every panel meeting. Early decisions included how best to (1) focus the guideline and literature review, (2) rate the strength of evidence underlying practice recommendations, and (3) determine the relationship between strength of evidence and strength of recommendation. In the absence of data, or when panelists did not share a common opinion, the panel attempted to achieve a consensus. An example of this process--when and how patients should be evaluated for possible coronary artery revascularization--is discussed at length. Unlike previous AHCPR guideline panels, this panel solicited opinions of national experts early and often during guideline development. This process helped the panelists arrive at conclusions on certain controversial issues. The guideline development process was complex and painstaking. The panelists and project staff believe that frequent peer review helped produce a guideline that can be widely accepted across clinical and geographic lines.