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Profile of the Consensus Development Program in Finland: The Medical Research Council of The Academy of Finland Anna-Liisa Kauppila NATIONAL CONTEXT The Medical Research Council (MRC) of the Academy of Finland has initiated the organization of consensus development conferences. The Academy of Finland is the central government agency for sci- ence administration and science policy planning. The primary task of the Academy is to fund and promote basic research. The Acad- emy attempts to increase the resources for scientific research, to improve the efficiency of Finnish scientific research, to coordinate research work across administrative boundaries, and to plan research and science policy in Finland. The MRC is one of the Academy's seven councils. The MRC members are leading researchers and represent the faculties and the departments of community health in the medical schools as well as other research institutes in Finland. The evaluation of scientific issues occurs at the Academy because of the increased demand for technology assessments and the increased desire for better interaction between the research community, the politicians, and Finnish citizens. The purpose of the consensus development conference program of the MRC is to raise interest in developing the assessment of health care technology in Finland. The MRC is the primary agency for organizing and sponsoring consensus development conferences for medical technology assessment. The MRC seeks the cooperation of 102

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MEDICAL RESEARCH COUNCIL OF THE ACADEMY OF FINLAND 103 the League of Hospitals and the Institute of Public Health and, de- pending on the theme of the conference, the support of any appropri- ate association or nonprofit corporation. Three consensus develop- ment conferences have been sponsored in Finland. The first confer- ence, held in 1985, was on the treatment of acute otitis media; the second, in 1987, was on the treatment of schizophrenia; and the third, in April 1989, was on cholesterol and coronary heart disease. The consensus development method is a readily available method of assessment for adoption and adaptation in any national health care system. The desire to start the program was due both to an interest in the consensus development method itself and the need to apply the method in a practical situation when there was controversy over the appropriate use of a particular medical technology. The experience of the first conference on the treatment of otitis media was encouraging. The MRC hopes to gain experience on the use of the consensus development conference and to find ways to adapt the method to the needs of the Finnish health care system. The principal goals of the Finnish consensus development confer- ences have not yet been fully defined, as the program is relatively new. Different goals were established in planning each conference. At present, the main goals of the program include the accumulation of experience with the method, development and adaptation of the method, and evaluation of the impact of consensus development conferences. The main purpose of each conference is similar to that of conferences conducted by the National Institutes of Health (NIH) in the United States, that is, to evaluate publicly the scientific infor- mation on health care technologies and to arrive at a consensus statement that will be useful for health care providers, researchers, and the public. Individuals from a variety of disciplines participate in the attempt to reach consensus on different topics. Researchers, practitioners, health care providers, and planners in health care at the community and national levels are included in the evaluation of the appropriate use of a technology and the implications of this use for patients and society. At present, the practical goals of the program are to: provide a setting for the evaluation and review of the scientific evidence in support of or in opposition to the use of a health or health-related technology disseminate information from researchers to clinical practitio- ners, health care providers, and consumers

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104 CONSENSUS DEVELOPMENT facilitate the diffusion, adoption and appropriate use of sound technologies by reaching the decision makers in health care or other appropriate sectors, for example national legislators identify gaps in the current state of knowledge for a technology in order to initiate research. The National Board of Health sponsors the publication of the consensus statements and participates in the dissemination of the consensus report. Administrators of the National Board of Health have served as members of the panel in two conferences. The Na- tional Board of Health is very interested in the consensus develop- ment program, although it does not have an official role in organiz- ing the conferences. The primary intended users of the consensus statements vary ac- cording to the theme of the conference. For example, the confer- ence on acute otitis media targeted clinical practitioners, whereas the conference on cholesterol and coronary heart disease addressed a wide range of interested parties, from the providers of agricultural products and nutritionists to clinical practitioners. SCOPE OF THE PROGRAM The Finnish program has no set priorities as to the kind of tech- nologies to be assessed (e.g., drugs, devices, or procedures). The technologies may be new or established; and the technologies con- sidered may be for prevention, diagnosis, treatment, or rehabilita- tion. A working group of the MRC plans consensus development con- ferences, although the MRC makes the final decisions with regard to topic selection and the membership of the planning committee. The MRC chooses the conference topic from a list of suggestions com- piled by the working group. The MRC officially solicits topic suggestions from a wide group of interested parties, including the National Board of Health; the Hospital League of Finland; the mem- bers of the MRC; and the staffs of university hospital clinics, med- ical schools, and the departments of community health. The MRC has not strictly defined topic priorities, although the basic criteria for selection resemble those used by NIH, as follows. 1. The subject under consideration should be medically important and should address major national health problems.

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MEDICS MESH COUNCIL OF THE ACHY OF FINED 105 2. There should be a scientific controversy or a gap between cur- rent knowledge and practice or variation in practice. 3. An adequately defined base of scientific information must be available on the topic. 4. The potential to obtain consensus must exist. 5. There should be public interest in the issues addressed. The issues addressed in a consensus development conference usu- ally include the safety, efficacy, effectiveness, service requirements, adoption level, and economic implications of the technology, as well as social, psychological, ethical, or legal considerations as appropri- ate. The Finnish MRC holds the multidisciplinary approach to the broad assessment of technologies to be of great importance for the consensus development conference process. FORMAT AND CONDUCT OF THE PROCESS The planning process for a consensus development conference takes approximately a year and a half. The solicitation of topics from a wide range of interested parties by the MRC marks the start of the planning process. This initial planning phase for topic selec- tion is carried out by a small working group on consensus develop- ment conferences. This group invites specialists to join in the initial planning phase as necessary. Knowledgeable researchers prepare papers on two or three topics to explain the criteria for selection of the particular subject. The primary organizations involved in the consensus development program (the National Board of Health, the League of Hospitals, and the Institution of Public Health) come to agree that the topic is the most suitable for consideration before the conference occurs. The MRC selects the most popular suggestions for topics and then nominates the full conference planning commit- tee. The chairperson of the planning committee is usually a member of the MRC with experience in the consensus development process. Members of the MRC working group also participate in the planning committee. The MRC identifies outside experts to participate in the planning committee. These individuals are the primary advocates of controversial opinions on the topic to be assessed. Two or three critics of the technology serve on the planning committee. The potential chairperson for the conference and other nonbiased experts .

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106 CONSENSUS DEVEL1)PMENT in a variety of fields participate on the committee. A representative of the League of Hospitals also takes part in the planning process. The planning committee carefully considers the selection of the chairperson for the conference. All members of the committee must agree on the choice of the chairperson. He or she is usually a distinguished researcher who possesses the personal skills to suc- cessfully lead the pane} toward consensus. The conference chair is invited to join the planning committee if the individual selected is not already a member of the committee. The planning committee formulates the consensus questions and the conference agenda. The committee devotes substantial effort to the definition of consensus development questions. The different viewpoints of the members of the planning committee are reflected in the conference agenda and in the selection of speakers. In order that all views be represented in the program, discussants may be chosen together with the speakers. A discussant reviews a speaker's paper before the conference and then provides criticisms or com- ments on the speaker's viewpoint. The planning committee is con- sidered crucial to the consensus development conference process, as the expertise of the group allows for the identification of speakers and discussants and the definition of an appropriate agenda. The planning committee acts as He nucleus of the consensus develop- ment process. All appropriate experts are represented as speakers, including basic researchers, clinicians, epidemiologists, health economists, psycholo- gists, and representatives from a variety of other disciplines. Nutri- tionists and representatives for the agricultural production industry participated as speakers in the 19X9 conference on cholesterol. Speak- ers present both their own data and overviews of other available scientific data for their 15- to 20-minute presentations. The planning committee must fully agree as to the selection of panel members. The committee carefully selects a pane} with the appropriate range of expertise for the particular conference. Re- searchers, clinicians, planners, administrators, and other health care providers are represented on the panel. Panelists should not be advocates of a particular position on the topic. Representatives of the public on the pane} may be editors of scientific journals or ex- perts from other areas, for example, social sciences or information sciences. Designated patient representatives have not been included as panel members, although individuals chosen for their appropriate

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MEDICAL RESEARCH COUNCIL OF TIlE ACADEMY OF FINLAND 107 expertise in a specific field may at one time have been patients. Speakers and members of the audience present the patients' perspec- tives. The size of the pane} has varied; in the consensus develop- ment conference on cholesterol there were 16 panel members. The basic format for a conference is similar to the NIH model and occurs over a period of two and a half days. The Finnish format continues to evolve, as each conference has been slightly different. The conference is an open, widely announced public meeting. Members of the medical community and the public are invited. Be- tween 100 and 160 people have attended consensus development conferences. The pane} receives copies of the speakers' presentations, includ- ing all tables and graphs, three to four weeks before the conference. For the most part, panels meet one or two times before the actual conference occurs. The pane] also meets the night before the actual public conference. During the preconference meetings the pane! members discuss as a group their methods of approaching the state- ment (e.g., how groups should be composed to focus on specific questions) and of considering the presentations by speakers. The pane! has the opportunity to raise additional issues or concerns for an open discussion. The pane! can request additional information on the topic. The pane} members may elect to submit questions to the speakers, to address the issues raised during this open discussion or "ventilation session" in their presentations. The pane! may produce an introduction to their statement for discussion the night before the conference. The planning committee chair opens the conference with a brief introduction to the consensus development process. The chair of the speakers' group then provides background information on the tech- nology in question; the presenter summarizes areas where no contro- versy exists and a brief review of the relevant epidemiologic and scientific data. The first two days of the conference are devoted to plenary sessions where the experts deliver their presentations. This is followed by questions from the pane} and the audience in a public discussion. Nonbiased experts alternate as the chair for different parts of the consensus development conference; for example, differ- ent individuals chair sections of the public meeting that address particular questions. The chairs may be members of the planning committee or speakers. The pane! drafts the consensus statement in the evenings of the first and second days of the conference. The

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108 CONSENSUS DEVELOPMENT panel may work until the early morning hours of the third day. The development of consensus occurs throughout the planning process of the conference. The conference represents the nodal point for con- sensus developmenteither the pane} succeeds in agreeing on the statement or no resolution of the controversy occurs. The consensus statement is presented to the audience for discus- sion on the morning of the third day. During the final discussion of the statement, proposals for changes can be made that are based only on the evidence given by the speakers or by the audience during the two preceding days. The pane} will decide on any alterations fol- lowing this discussion. After this point, no changes can be made. The chair of the pane} presents the statement to the press. DOCUMENTATION AND USE OF EVIDENCE IN CONSENSUS DEVELOPMENT The planning committee is responsible for gathering material for the pane} and the conference. The panel receives background mate- rial two to three months before the conference. The background material consists of literature reviews, epidemiologic studies, re- ports of clinical trials, relevant journal articles, and any available summaries of the state of the science. The planning committee distributes speakers' papers to the pane} one month before the con- ference. The panel can only consider the evidence presented in the public meeting for development of the statement. The consensus statement does not include references to the materials used at the conference. DISSEMINATION AND IMPACT Announcements of the conferences appear in professional jour- nals and newsletters in the health care sector. Media representatives receive personal invitations to attend the consensus conference and the press conference on the last day of the meeting. Announcements are distributed by mail to a variety of individuals in health care, including the Hospital League, the Society of Health Care Assess- ment of Finland, medical schools, institutes, selected university de- partments, university clinics, central hospitals, health administrators, communal administrators, etc. The consensus statement is published in the main Finnish medical

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MEDICAL RESEARCH COUNCIL OF THE ACADE~lY OF FINLAND 109 journal shordy after the conference. A press conference occurs at the end of the consensus development conference, and a press re- lease is distributed. The statement and the speakers' papers are published as a single document through the cooperative endeavors of the Finnish Academy and the National Board of Health. The sponsoring organizations are responsible for the dissemination of the report to members of their societies. To date, the impact of the consensus development program has not been formally evaluated.