Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 118
Profile of the Consensus Development
Program in Norway: The Norwegian
Institute for Hospital Research and
The National Research Council
Bj0rn Backe
NATIONAL CONTEXT
The Norwegian Institute for Hospital Research (NIHR) initiated
the first consensus conference, Use of Ultrasound Screening in Preg-
nancy, in 1986. This nonprofit, health services research institute
mainly conducts health planning and contract research for health
authorities and hospital owners. The NTHR arranged the first con-
sensus development conference in cooperation with the Health Ser-
vices Research Unit of the National Institute of Public Health. The
NTHR sponsored the conference in conjunction with the Royal Nor-
wegian Ministry of Health and Social Affairs.
In 1987, the Ministry of Health and Social Affairs asked the Nor-
wegian National Research Council (NRC) to develop a program for
consensus development conferences in Norway. The NRC recom-
mended a three-year program with two consensus development con-
ferences per year. At present, the Norwegian Institute for Hospital
Research and the NRC work together to organize and finance the
consensus development program. The first conference in this pro-
gram, on mammography screening, occurred in February 1989. The
second conference, on reduction of the population's cholesterol level,
occurred in October 1989.
The purpose of the program is to improve the policy and practice
for areas of concern in the health services by providing objective
~8
OCR for page 119
NORWEGIAN IN=I~E FOR GOSPEL INCH
119
information on controversial medical matters for political and ad-
ministrative decision makers, medical professionals, patients, and
general consumers.
The pane! from the first conference on ultrasound in pregnancy
recommended that one routine examination should be offered to all
pregnant women (Norwegian Institute for Hospital Research, 1987~.
The Directorate of Health immediately endorsed the statement as the
national guidelines for obstetrical use of ultrasound. Recent re-
search indicates that the consensus development conference state-
ment has had a measurable influence on the practice of ultrasound
(Nafstad and Backe, 1989~. Two national cross-sectional surveys of
ultrasound practice have been made: a short time before and two
years after He consensus conference. In this time period, there was
a reduction in the total number of examinations perfor-~ed and an
increase in the proportion of pregnant women being examined (98
percent). There are roughly 52,000 deliveries per year in Norway.
At present approximately 12,000 fewer examinations are performed
per year in Norway compared with the 1986 rate for the procedure.
The second consensus pane} noted Hat mammography screening
should not yet be routinely offered, pending the results of ongoing
research that is expected to provide further evidence toward resolu-
tion of the controversy. The Minister for Health and Social Affairs
referred to the statement in a parliamentary debate shortly after pub-
lication. She agreed with the consensus statement and stated that
the national guidelines (i.e., the treatment program for the use of
mammography) would be published in the near future, based on the
consensus development conference statement.
The national health authorities, the county hospital owners, and
the health professionals have used the statements from the Norwe-
gian consensus development conferences as a reliable form of ad-
vice. The two past conferences have been funded jointly by the
Royal Norwegian Department for Health and Social Affairs and the
NIHR. The total cost per conference is about NKr 382,580 (U.S.
$55,X51~. This includes direct costs for He planning group, confer-
ence report, informational material, and staffing, including overhead
costs.
The panelists and the expert presenters do not receive compensa-
tion for their participation. Funds for the conference are used to
employ the leader of the conference planning group. The planning
group leader may be one of the researchers at the NIHR who works
OCR for page 120
120
CONSENSUS DEVELOPMENT
part time with consensus development conferences or, in some in-
stances, may be employed on a short-term contract. The planning
group leader is responsible for the financial aspects of the consensus
development conference program. For the most part, the planning
group leaders have been involved in research projects that addressed
issues concerning the particular topic for the consensus development
conference.
SCOPE OF THE PROGRAM
A medical technology must meet the following criteria before
assessment by the consensus conference method.
· The technology must be of broad general interest.
The ethical, social, and/or other consequences must be large.
The number of patients must be large, or the costs great.
· The topic is within the medical-scientific framework (i.e., there
must be enough scientific evidence for the questions to be answered
on a scientific basis).
· There must be disagreement as to the utility of the technology
(i.e., there must be a real dispute within the medical profession on
how to interpret the available scientific results. and how to aDDIv the
technology in practice).
. . ~
· The statement should have the ability to influence He diffusion
of the technology and to alter current clinical practice.
The term medical technology broadly defines those instruments,
practices' and procedures based upon medicaVbiological knowledge.
The Norwegian program does not have explicit limitations as to the
appropriate stage in the life cycle of a technology for assessment by
a consensus development conference. The program will probably
focus upon new and established technologies.
At present, NRC and NTHR are collecting suggestions for future
conference topics. NRC established a subcommittee on technology
assessment: the TA committee. Two health services research insti-
tutes, the Royal Norwegian Ministry for Health and Social Affairs
and the Directorate of Health, are represented on the TA committee.
The committee chair is a representative of the Medical Research
Council.
The TA committee selects conference topics, drafts the questions,
and appoints a planning group for each conference. As a rule, both
OCR for page 121
NORWEGIAN INS17TlrTE FOR HOSPITAL RESEARCH
121
the chair of the consensus panel (appointed by the TA committee)
and one or more of the topic experts in the field participate in the
planning group. The planning group refines the questions for the
panel, selects panelist and experts, and prepares the practical ar-
rangements for the conference. The work of the planning group is
subject to the approval of the TA committee.
The aspects of a technology addressed at a consensus develop-
ment conference include effectiveness and efficacy (or practical,
achievable health benefits); health risk; monetary cost; and organ-
izational, ethical, social, and psychological consequences of increased
or decreased use of a technology. Equal access to the technology
(equity) is a particularly important consideration. The questions are
formulated so that the statements can be used as a basis for treat-
ment programs that serve as guidelines for the treatment of certain
conditions or patient groups. The consensus development confer-
ence statement itself is insufficient for use as a treatment program,
as treatment programs provide far more detail on patient care.
FORMAT AND CONDUCT OF THE PROCESS
The necessary preparation time for a consensus development con-
ference, from the selection of a topic to the composition of the
consensus statement, is approximately one year. The conference it-
self lasts two and a half days; the pane} completes the statement
during the second night of the conference.
The pane} members are offered assistance from NTHR in the as-
sembly of relevant literature. Panelists received reports of pertinent
randomized controlled trials (RCTs) and other relevant literature
before the two recent conferences. No formal protocol exists for the
distribution of information to the panel before each conference. The
chair of the panel and the planning group decide upon a procedure
for materials procurement and dissemination for the individual con-
ference.
The Norwegian program does not have a formal procedure for
selection of the panelists. Approximately half of the panel is to
come from the medical profession, including experts in epidemiol-
ogy and statistics, community medicine, and general practice, as
well as experts in other medical fields who are familiar with the
technology in question but who are not experts on the subject. The
nonmedical members of the panel are experts in health economics,
..
OCR for page 122
122
CONSENSUS DEVELOPMENT
ethics, law, health journalism, health administration at various lev-
els, and health politics.
As a rule, the panelist should not have expressed strong opinions
on the consensus topic. They are invited as individuals, rather than
as members or representatives of groups or organizations. They are
experts in their fields, although they are not necessarily experts on
the topic of the conference. They receive both written and oral
information on the concept of consensus development. In general,
the panel of representative, well-informed individuals seeks to achieve
consensus through discussion and debate.
The conferences are public meetings with short scientific presen-
tations by experts (15 minutes each) that are followed by discus-
sions.- During the general discussion period, the panel members
question the experts. Questions and comments may also come from
the audience. Approximately 200 people attended the first two con-
ferences, most of whom were physicians.
On the morning of the third day, the pane} presents the consensus
statement. The panel prepares the final version of the statement
without the assistance of any other individuals. The pane} meets
privately a number of times during the conference. The first closed
session occurs the evening before the start of the public presenta-
tions.
DOCUMENTATION AND USE OF EVIDENCE IN
CONSENSUS DEVELOPMENT
The first two Norwegian conferences focused upon technologies
for health screening. In both cases, the question of utility rested
heavily upon a small number of RCTs (four and three studies, re-
spectively). If the RCTs were performed in Nordic countries, the
principal author presented the material. In other cases, the confer-
ence planners commissioned an expert to present the material.
The experts must submit a written abstract of their oral presenta-
tion. Panelists receive the abstracts a minimum of four weeks be-
fore the conference. The working language throughout the confer-
ence is Norwegian.
As a rule, only published evidence has been considered. Docu-
mentation of both the state of knowledge and the state of practice
are important elements of the consensus development conference
process. Often studies must be performed before each conference to
OCR for page 123
NORWEGIAN IN517TUTE FOR HOSPITAL RESEARCH
123
estimate the actual diffusion, use, costs, and health effects of He
relevant technology. Appropriate institutions and experts are com-
missioned to prepare reports in these cases.
Panelists do not adhere to any formal guidelines for weighting the
presentations. The pane! reaches consensus through discussion. The
process is not rigidly structured. References are not available in the
consensus statement, as they are not considered to be necessary.
The panels do, however, provide conclusions and detail the reason-
ing behind the consensus statement.
DISSEMINATION AND IMPACT OF THE CONSENSUS
STATEMENT
After each conference, the proceedings are published in a report,
together with the consensus statement and a short review of the
main reasons for holding He conference. The mechanisms for dis-
semination of the consensus findings include:
· press conference
· newsletter to the media
distribution of the statement to administrative authorities
publication of the statement in the Journal of the Norwegian
Medical Association and distribution of the statement to over ap-
propriate journals, and to radio, television, and over news media.
An evaluation of the impact of the first conference (which was
held in 1986) is in progress as a part of a thesis on the diffusion of
medical technologies. The previously mentioned study of the prac-
tice of ultrasound before and two years after the consensus develop-
ment conference was presented at the June 1989 meeting of the
International Society of Technology Assessment in Heals Care (Backe
and Nafstad, 1989~. The sponsoring organizations are currency
considering the feasibility of an evaluation of the ongoing three-year
program.
REFERENCES
Backe, B., and P. Nafstad. 1989. Development in practice of diagnostic ultrasound
in Norway after the consensus conference recommending routine screening (ab-
stract). Presented at the annual meeting of the International Society of Technol-
ogy Assessment in Health Care, London.
OCR for page 124
124
CONSENSUS DEKELOPMENT
Nafstad, P., and B. Backe. 1989. Prevalence and practice of obstetrical ultrasound
in Norway (in Norwegian). Tidsskr Nor Laegeforen 109:2975-2978.
Norwegian Institute for Hospital Research. 1987. Ultrasound in pregnancy: Con-
sensus statement, 1986. International Journal of Technology Assessment in Health
Care 3(3):463-470.
Representative terms from entire chapter:
development conference
