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Consensus
Development
at the NIH
Improving the Program
Report of a Study by a Committee of the
Institute of Medicine
Council on Health Care Technology
NATIONAL ACADEMY PRESS · WASHINGTON, D.C. · 1990
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NOTICE: The project that is Me subject of this report was approved
by the Governing Board of the National Research Council, whose
members are drawn from the councils of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of
Medicine. The members of me committee responsible for the report
were chosen for their special competences and with regard for ap-
propriate balance.
This report has been reviewed by a group other than the authors
according to procedures approved by a Report Review Committee
consisting of members of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National
Academy of Sciences to enlist distinguished members of the appro-
priate professions in the examination of policy matters pertaining to
the health of the public. In this, the Institute acts under both the
Academy's 1863 congressional charter responsibility to be an ad-
viser to me federal government and its own initiative in identifying
issues of medical care, research, and education.
Support for this project was provided by the National Institutes of
Health, Office of Medical Applications of Research, pursuant to
Contract No. NO 1-OD-8-21 10.
Library of Congress Catalog Card Number 90-60935
International Standard Book Number 0-309-04242-9
Publication IOM-90-04
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, N.W.
Washington, D.C. 20418
S131
Printed in the United States of America
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Acknowledgments
The committee thanks the individuals who provided insight into
the National Institutes of Health Consensus Development Program.
In particular, the committee acknowledges Donald S. Fredrickson,
former director of the National Institutes of Health; John Ferguson,
director of the Office of Medical Applications of Research; Jerry
Elliott, program analyst, Office of Medical Applications of Research;
and Jacqueline Kosecoff, executive vice president of Value Heath
Sciences, Inc., and professor of medicine and public health, Univer-
sity of California at Los Angeles.
The committee would like to express its appreciation of the Insti-
tute of Medicine staff who facilitated the work of this committee,
especially Elaine Steen, Clifford Goodman, Sharon Baratz, and Ethan
Halm. We are grateful to Holly Dawkins and Evanson Joseph for
logistical support and help in preparing this manuscript.
The committee also thanks the members of He Council on Health
Care Technology and the Institute of Medicine Council, who re-
viewed and provided useful comments on the report.
· · ~
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COMMITTEE TO IMPROVE THE
NATIONAL INSTITUTES OF HEALTH
CONSENSUS DEVELOPMENT PROGRAM
COUNCIL ON HEALTH CARE TECHNOLOGY
Chair
J. SANFORD SCHWARTZ
Executive Director, Leonard
Davis Institute of Heady Eco-
nomics, Associate Professor of
Medicine and Health Care
Systems, and Robert D. Eilers
Associate Professor of Health
Care Management and Econom-
ics, University of Pennsylvania
MARCIA ANGELL
Executive Editor, The New
England Journal of Medicine
ROBERT H. BROOK*
Deputy Director, Health Sci-
ences Program, The RAND Cor-
poration, and Chief, Division of
Geriatrics and Professor of
Medicine and Public Health,
University of California at Los
Angeles
FLOYD W. DENNY*
Professor of Pediatrics, School
of Medicine, University of
North Carolina at Chapel Hill
ROBERT M. DONALDSON, JR.
Deputy Dean, Yale University
School of Medicine
~Member, l~stitute of Medicine
V
DENNIS PAYBACK
Professor of Industrial Engineer-
ing and of Preventive Medicine,
University of Wisconsin-Madi-
son
ARNOLD D. KALUZNY
Professor of Health Policy and
Administration, School of
Public Health, University of
North Carolina at Chapel Hill
R. BRIAN HAYNES
Professor of Clinical Epidemiol-
ogy and Medicine, McMaster
University
JONATHAN LEFF
Editonal Consultant, Former
Director, Consumer Reports
Books, South Hero, Vermont
STEPHEN G. PAUKER
Professor and Chief, Division of
Clinical Decision Making, De-
pa~tment of Medicine, New
England Medical Center, Tufts
University School of Medicine
CAROL K. REDMOND
Professor and Chair, Depart-
ment of Biostatistics, Graduate
School of Public Health, Uni-
versity of Pittsburgh
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INSTITUTE OF MEDICINE
SAMUEL O. THIER, President
ENRIQUETA C. BOND, Executive Officer
Project Staff
CLIFFORD GOODMAN, Director, Council on Health Care
Technology
ELAINE B. STEEN, Project Officer
SHARON R. BARATZ, Research Associate
HOLLY DAWKINS, Project Assistant
EVANSON JOSEPH, Project Assistant
V1
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Preface
One of the goals of the Institute of Medicine's Council on Health
Care Technology has been to promote the development and applica-
tion of technology assessment in health care. Assessment of medi-
cal technologies currently relies extensively on group judgment or
"consensus development" processes. These methods are used by
medical professional societies, private and public third-party payers,
biomedical research agencies, and others to assess state-of-the-art
medical and surgical procedures and other technologies, to define
standard and accepted medical practices, to bridge gaps and resolve
disparities among research findings, and to establish coverage and
reimbursement policies. Despite the often weighty implications for
health policy of decisions based on group judgment, these processes
often are applied with little systematic or critical examination of
their conduct, utility, or appropriateness for technology assessment.
The panels convened for group judgment must weigh, integrate,
and interpret the available evidence, experience, beliefs, and values
in order to formulate guidelines, recommendations, or other find-
ings. The technologies assessed may be evolving rapidly; the evi-
dence available to the panels may consist of a sparse patchwork of
research results of varying quality. Panelists may be subject to
biases and errors of reasoning; experts and nonexperts alike may be
vii
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V111
PREFACE
subject to oversimplification, empiricism, case-selection biases, in-
centives, and advocacy.
Group judgment methods have been developed and used in many
fields, including the social, political, physical, and biomedical sci-
ences; engineering; defense; environmental studies; and other do-
mains. To improve group judgment for assessing medical technolo-
gies, the council urges programs to learn from alternative techniques
and models used in other fields for engaging groups of experts in
rendering well-founded and informed findings.
The council is conducting a three-part examination of group judg-
ment methods for assessing medical technologies: an international
workshop on consensus development for medical technology, a study
to improve the National Institutes of Health (NIH) Consensus De-
velopment Program, and a workshop to improve group judgment for
medical practice and technology assessment. First, in conjunction
with the June 1989 annual meeting of the International Society for
Technology Assessment in Health Care, the council coordinated a
workshop that compared and contrasted national consensus develop-
ment programs. The proceedings of the workshop (Improving Con-
sensus Development for Health Technology Assessment: An Inter-
national Perspective, C. Goodman and S. Baratz, eds., 1990), in
which representatives of ~ ~ countries participated, include a consoli-
dated set of participants' recommendations for improving these ap-
proaches. Second, as requested by the NTH Office of Medical Ap-
plications of Research, a committee operating under the aegis of the
council conducted a November 1989 meeting and follow-up work to
review and provide recommendations for improving the NTH Con-
sensus Development Program. The committee's recommendations
are presented in this report. Third, a May 1990 workshop sponsored
by the council will convene those who conduct, participate in, and
use the results of group judgment efforts of medical professional
societies, third-party payers, regulatory agencies, and others. This
workshop will focus on improving key methodologic aspects of these
programs and sharing newer approaches to improve their application
for rendering practice guidelines, coverage decisions, and other as-
sessment-related findings and policies.
The councilts goal in undertaking this three-part effort is to im-
prove group judgment for assessing medical technologies. This re-
port makes a significant contribution toward that goal. Although
written specifically for the NIH Consensus Development Program,
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PREFACE
1X
the recommendations presented in this report address many of the
challenges of any group process intended to produce a consolidated,
well-substantiated expert judgment for direct application to policy-
making. Furthermore, by requesting this evaluation, NIH may en-
courage others in the field to undertake efforts to examine and im-
prove their group judgment efforts.
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Contents
Summary .......
1. Introduction.........................
2. Recommendations for Program Structure
3. Recommendations for Program Function.
References ............
· —
3
9
.18
34
Appendixes
A. Background Paper for the Committee to Improve the National
Institutes of Health Consensus Development Program .... 41
Sharon R. Baratz
B. NTH Consensus Development Conferences..............
C. Questions from NIH Consensus Development Conferences
(October 1987-September 1989~.
D. General Bibliography on Consensus Development
X1
65
71
75
· · ~
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