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Profile of the Consensus Development Program in The Netherlands: National Organization for Quality Assurance in Hospitals (CBO) Nick S. Klazinga, Anton F. Casparie, and I. I. E. van Everdingen NATIONAL CONTEXT The origin of the CBO (Centraal Begeleidingsorgaan voor de In- tercollegiale Toetsing, or National Organization for Quality Assur- ance in Hospitals) consensus development process lies in the quality assurance activities of medical specialists in hospitals (Klazinga et al., 19881. In the early 1980s, it became evident that it was difficult to develop criteria for audit studies at the hospital level for several controversial medical topics. The development of guidelines for medical practice on a national level was needed. In 1981, the Scien- tif~c Council of CBO decided to start a consensus development pro- gram similar to the one conducted by the National Institutes of Health in the United States. CBO is an independent nonprofit organization founded in 1979 by the Dutch Specialists Association and the Asso- ciation of Medical Directors. The Scientific Council of CBO repre- sents all 34 scientific medical associations in The Netherlands. The purposes of the CBO consensus development program are (~) to establish guidelines on controversial medical issues and (2) to en- sure the quality of care by promoting behavioral change among medical practitioners (Casparie and van Everdingen, 1985a, b). The primary goal of the consensus development program is to develop guidelines for daily medical practice such that they not only ~10

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NE~ERIANDS CBO 1.11 represent the state of the art but also are acceptable to the medical community. The program is run for and by the profession itself (scientific associations), but finds recognition among financiers, government authorities, and patients' organizations. In recent gov- ernment policy papers, consensus development is mentioned as one of the profession's contributions to quality assurance. The clini- cians (specialists, general practitioners, nurses, physiotherapists, etc.) are the intended primary users of the consensus statements; how- ever, recommendations may also be of interest to hospital adminis- trators and policymakers (Casparie et al., 1987~. There are usually four conferences each year with an average attendance of 300 individuals per conference. The total yearly cost of the program is approximately OFF. 400,000 (U.S. $200,000~. This includes costs for personnel, materials, meeting arrangements, over- head, etc. SCOPE OF THE PROGRAM The program assesses selected clinical problems. The choice of technology to be assessed depends on the problem in question: Drugs, devices, medical or surgical procedures, support systems, and organ- izational or administrative systems may be examined. Technologies for discrete stages of intervention are discussed for different clinical conditions; for example, prevention of bedsores, diagnosis of deep venous thrombosis, and treatment for osteoporosis (van Everdingen and Caspar~e, 19XX; van Everdingen et al., 1988~. Table ~ lists the CBO consensus development programs that have taken place over the years. Some of the technologies assessed are new (used only by practitioners in university hospitals) or already established and/or widespread. Some have been labeled as obsolete during the process of consensus development. The properties of a technology that are normally addressed are safety, efficacy, effectiveness, and, to a lesser extent, cost-effective- ness and service requirements. Suggestions for consensus develop- ment topics come from scientific associations, peer review commit- tees in hospitals, or medical foundations such as The Netheriarlds Heart Foundation (consensus on cholesterol). The Scientific Coun- ci} of CBO is responsible for final selection of topics.

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112 CONSENSUS DEVELOPMENT TABLE ~ CBO Consensus Development Program Year Program 1982 Blood transfusion therapy 1983 Traumatic lesions of the back Mammography policy 1984 Severe brain damage Melanoma of the skin Thrombocyte transfusion policy 1985 Solitary thyroid nodules Prevention of bedsores Osteoporosis Foot problems of diabetic patients 1986 Diagnosis of deep venous thrombosis Nonscrotal testis Treatment of bedsores Drug addicts in prison Hypercholesterolemia 1987 Prevention of herpes neonatorum Hemophilia Follow-up colon polyps Cholesterol Suspect lymph nodules in the neck Diagnosis of atopic syndrome Total hip joint replacement Follow-up of colorectal cancer 1988 Diagnosis of dementia Sports and cardiac pathologies 1989 Prevention of deep venous thrombosis Prevention of hospital infections 1990 Diagnostics for lung carcinoma Hypertension Acute otitis media Nutrition and allergy 1991 Cerebrovascular accident Diabetic retinopathy Treatment of deep venous thrombosis

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NETHERLANDS CBO The following criteria are applied in the choice of topics: controversial in the literature and among practitioners relevant in terms of health benefit feasibility of consensus development relevant for medical practice sufficient scientific data available. FORMAT AND CONDUCT OF THE PROCESS 113 The consensus development process requires about two years. First, a topic is selected by the Scientific Council of COO, and then a suitable chair is selected for the working group. Formation of the complete working group takes about three months. All members of the working group are experts and official representatives of their respective scientific associations. Representatives from the fields of nursing, physiotherapy, and general practice are invited to partici- pate as needed. During the following 12 months, the working group meets six to ten times to develop a syllabus with background infor- mation and to draft consensus statements. The consensus development conference takes place after comple- tion of the draft statements by the working group. All practitioners and interested persons can attend the conference; attendance has ranged from 150 to 1,000 individuals. The conference itself lasts one to two days. Two weeks in advance of the conference, partici- pants receive the syllabus with background information and drafts of proposed consensus statements. AR statements are defended by the working group as a whole. After each presentation, there is ample time for questions; later in the program the audience may comment on the draft consensus statements. Considerable time is allocated for discussion between members of the audience and members of the working group. At the end of the day, the chair summarizes the results and tries to formulate a definite set of consensus guidelines. The chair asks the audience explicitly whether they agree with the consensus text, and then he closes the meeting. One month after the consensus development conference, the working group meets for the last time to finalize the text of the consensus statement for publica- tion.

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114 DOCUMENTATION AND USE OF EVIDENCE IN CONSENSUS DEVELOPMENT CO]VSE NSUS DEKELOPME~ The information used during the consensus development process comes from the experts in the working group. Sometimes, formal literature searches are performed on a small scale, but in most cases the experts bring in literature as well as their own material. The working group may use reports of clinical trials, epidemiologic stud- ies, and literature reviews for particular topics (Klazinga et al., 1987~. The available evidence was weighed systematically on several occa- sions according to the memos proposed by Sackett during the Na- tional Institutes of Health conference on the prevention of venous thrombosis and pulmonary embolism, March 24-26, 1986 (Sackett, 1986~. On other occasions, the evidence collected from the litera- ture and the experts' experience was combined. In the syllabus written by the members of the working group, reference is made to the data used during the consensus development process. The most important literature is also mentioned in the text of the final consen- sus statement. DISSEMINATION AND IMPACT CBO consensus development conferences are widely announced to reach physicians in The Netherlands via professional journals and direct mailing to the appropriate specialty groups. Announcements are posted in hospitals to attract attention. The final consensus statements are published in the Nederiands Tij~schrift boor Geneeskunde (a Dutch medical journal); and copies are sent to those who attended the conference as well as all medical staff, hospital administrators, and chairpersons of peer review committees. Scien- tif~c associations that cosponsor the consensus development confer- ence sometimes send the consensus results to their members. The text can be purchased from CBO, and the CBO staff is also active in disseminating the consensus reports to hospital practitioners who are involved in quality assurance. In a few cases, follow-up meetings have been held for specialists who were unable to attend the consen- sus development conference. The consensus statements are intended to change clinical practice by altering physician behavior. This is why CBO works for large- scale commitment and involvement of medical specialists in the

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NEI~ERL4NDS CBO 115 consensus development process. Although the consensus guidelines have no legislative bearing, they acquire status from the involve- ment of the different scientific associations and experts. The CBO consensus development program has been evaluated in terms of both process and effect (van Everdingen, 1988~. Evaluations have ad- dressed: the consensus meeting process and the activities in the working groups impact of awareness of consensus guidelines among medical practitioners impact of consensus guidelines by practitioners (formulation of protocols and criteria setting for audit studies in hospitals) effects of consensus guidelines on the behavior of medical spe- cialists (on the hospital and national levels). The evaluation activities of CBO are summarized in Table 2. REFERENCES Casparie, A.F., and J.J.E. van Everdingen. 1985a. Consensus development in The Netherlands. European Newsletter on Quality Assurance 2:1, 5. Casparie, A.F., and J.J.E. van Everdingen. 1985b. Consensus development confer- ences in The Netherlands. International Journal of Technology Assessment in Health Care 1~4~:905-912. Casparie, A.F., N.S. Klazinga, J.J.E. van Everdingen, and P.P. Touw. 1987. Health- care providers resolve clinical controversies: The Dutch consensus approach. Australian Clinical Review 7~24~:43-47. Klazinga, N.S., A.F. Casparie, and J.J.E. van Everdingen. 1987. Contribution of medical decision-making to consensus development conferences. Health Policy 8:339-346. Klazinga, N.S., A.F. Casparie, and J.J.E. van Everdingen. 1988. Quality assurance on the crossroad of medical decision making and management of the health care process in the hospital (abstract). Theoretical Surgery 3:4243. Sackett, D.L. 1986. Statistical issues in clinical trials. Pp. 3640 in Program and Abstracts for the NIH Consensus Development Conference on the Prevention of Venous Thrombosis and Pulmonary Embolism. Bethesda, Md.: Office of Medi- cal Applications of Research. van Everdingen, J.J.E. 1988. Consensusontwikkeling in de Geneeskunde. Thesis (English summary). Utrecht, Bonn: Scheltema & HoLicema. van Everdingen, J.J.E., and A.P. Casparie. 1988. Consensus development confer- ences on osteoporosis (letter to the editor). British Medical Journal 296:61-62. van Everdingen, J.J.E., N.S. Klazinga, and A.F. Casparie. 1988. Blood transfusion policy in Dutch hospitals. International Journal of Health Care Quality Assur- ance 1:16-19.

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