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OCR for page 125
Profile of the Consensus Development
Program in Sweden: The Swedish
Medical Research Council and
The Swedish Planning and
Rationalization Institute for the Health
and Social Services
Ste fan Hikansson and Ingemar EckerIund
NATIONAL CONTEXT
Sweden was the first country outside of the United States to adopt
the consensus development conference as a method for technology
assessment (Calitorp and Smedby, 1989~. The format of the Swed-
ish conferences follows the U.S. National Institutes of Health model
quite closely. Since 1982, 11 consensus development conferences
have been arranged jointly by the Swedish Medical Research Coun-
cil (MFR) and the Swedish Planning and Rationalization Institute of
the Health and Social Services (Spri).
The goal of each conference is to reach consensus among special-
ists from different disciplines concerning the safety, benefit, and
appropriate use of a particular medical technology. Practicing phy-
sicians, representatives of the lay public, health care administrators,
and politicians often participate. Swedish consensus development
conferences have three major purposes:
I. to review and assess the scientific base for a medical technol-
ogy
2. to contribute to He dissemination of knowledge concerning
the technology
3. to provide information concerning the appropriate use of the
technology.
125
OCR for page 126
126
CONSENSUS DEVELOPME:NT
The cost of a Swedish consensus conference is about Skr 500,000
(about U.S. $75,000) in 1989 prices. This includes costs for plan-
ning, staffing, and report dissemination and overhead costs associ-
ated with consensus development activities. The costs are equally
divided between the MFR and Spr'.
SCOPE OF THE PROGRAM
Since 1982, the following consensus development conferences have
been held:
Total Hip Joint Replacement (1982)
· Treatment of Myocardial Infarction (1983)
· Treatment of Depressive Disorders (19X4)
· Sight Improving Surgery (1984)
· Diagnostic Imaging of Liver Tumor (1985)
· Cerebral Hemorrhage and Stroke Diagnosis and Treatment
(1986)
· Urinary Incontinence in Adults Diagnosis and Treatment (1986)
· Chronic Leg Ulcers Diagnosis and Treatment (1988)
· Postoperative Wound Infections—Hygienic Routines in Hospi-
tal (1988)
· Preoperative Routines (1989)
· Venous Thrombosis Diagnosis, Prevention and Treatment
Indications (1989~.
The types of technologies that have been addressed are primarily
medical and surgical procedures. Table ~ details the types of tech-
nological interventions and the stages in the life cycle of technolo-
gies that have been assessed by way of consensus development.
Safety, efficacy, effectiveness, cost, and economic implications
are technological properties or concerns that are usually addressed
during the consensus development conferences. Ethical, legal, or
social implications have hitherto played a relatively minor role.
The criteria for selection of a topic in the consensus development
program include the following.
· The topic should be medically important and have the potential
to eventually produce changes in medical practice (i.e., there is a
gap between current knowledge and current medical practice).
· The topic should be clearly defined, and a corresponding scien-
tific knowledge base must exist.
OCR for page 127
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OCR for page 128
128
CONSENSUS DEVELOPMENT
· It must be possible to answer the questions on technical scien-
tific grounds, and the result must not be biased by the subjective
values of the panel.
FORMAT AND CONDUCT OF THE PROCESS
The planning and implementation of the consensus development
conference process lasts from one to one and a half years. The
conference itself lasts for two and a half days.
The MFR's initiative group on the assessment of medical technol-
ogy considers topics for consensus development conferences. The
proposals from this group go to a steering committee, having repre-
sentation from the sponsoring organizations (MFR and Spri), which
in turn selects topics, develops conference questions, and appoints
participants to the panels and expert groups. Since 1985, both the
Federation of the County Councils of Sweden and the Swedish Soci-
ety of Medicine have been asked to suggest conference topics. The
conferences are planned in detail by special working groups ap-
pointed for each conference. These working groups usually consist
of the panel chair, the expert group, two representatives from each
of MFR and Spri, one representative from the Swedish Society of
Medicine, and one representative from the National Board of Health
and Welfare.
The panels normally consist of approximately 16-18 members.
About half of the panelists are medical experts, while the others
usually represent health economics, epidemiology, health policy,
administration, and concerned patient groups.
Although the format of the Swedish conferences follows the U.S.
model quite closely, the scope is somewhat broader. In addition to
the evaluation of the safety and efficacy of a technology, the Swed-
ish conferences address health care organization, cost effectiveness,
and social and ethical questions.
One and a half days are dedicated to expert presentations, includ-
ing questions and discussion. The speakers present not only their
own data but also general overviews of available data in order to
present the actual state of the art. The panel begins to write the
statement on the afternoon of the second day. On the third day the
panel presents the statement to the experts and the audience (ap-
proximately 200 individuals) for discussion. The panel meets again
OCR for page 129
SWEDISH MAR AND Spri
129
after this general session to decide on possible modifications. The
conference ends with a press conference.
DOCUMENTATION AND USE OF EVIDENCE IN
CONSENSUS DEVELOPMENT
The expert group assembles information for each consensus de-
velopment conference. The presentations by the experts are based on
various kinds of information. For example, reports of clinical trials,
epidemiologic studies, and literature reviews have been used as evi-
dence.
Panelists and participants receive paper abstracts about one month
before the conference begins. The consensus statement's validity
rests solely upon the scientific evidence presented to the pane} for
decision making. Information that has not been presented at the
conference is not to be considered by the panel. Only presentations
by the experts, distributed materials, and answers to the questions of
the panelists are to be taken into account in the panel's statement.
There are no explicit rules for the development of consensus and
the use of evidence during the executive sessions of the panel. The
panels for each conference decide upon the definition of consensus.
The chairperson leads the discussion and consideration of evidence
in the format chosen by the panelists.
The Anal product of the consensus development process is the
consensus statement. In general, consensus statements do not cite
articles used as evidence. Each consensus statement contains a list
of the members of the program committee, the expert speakers, and
the panelists.
DISSEMINATION AND IMPACT
Spri publishes the consensus statements and distributes them free
of charge to politicians, health care administrators, chief medical
officers, and concerned health care personnel. The statements are
also published in their entirety in the Journal of the Swedish Medi-
cal Association. The Swedish consensus statements~regularly re-
ceive considerable publicity through the radio and television media.
The press actively disseminates the key points of the statements.
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130
CONSENSUS DEKELOPME~T
A committee worked for two years to evaluate Swedish consensus
development conferences and to trace the impact of consensus state-
ments on the principal actors in me health care arena (Berfenstam et
al., 1986; CalItorp, 1988; lohnsson, 19XX). The studies were di-
rected toward the evaluation of the impact of the conference on
specialists in the actual specialties concerned and on the top admin-
istrators and politicians in the county councils.
Details of the evaluations were presented by Calitorp (1988) and
Johnsson (1988~. The main conclusions are as follows.
· The statements are very well known among all major groups
concemed. The politicians and administrators tend to report a higher
practical utility of the statements.
· The statements are regarded as good educational material, as
they provide useful background reading for planning and decision
making.
· The conferences and the statements could be influential in the
priority setting process within county councils.
REFERENCES
Berfenstam, R., G. Carlsson, and L. Werko. 1986. Konsensuskonferensers Roll och
Effekter. (The Role and Effects of Consensus Development Conferences.) Stock-
holm: Medicinska Forskningsradet, Spri.
Calltorp, J. 1988. Consensus development conferences in Sweden: Effects on health
policy and administration. International Journal of Technology Assessment in
Health Care 4:75-88.
Calltorp, J., and B. Smedby. 1989. Technology assessment activities in Sweden.
International Journal of Technology Assessment in Health Care 5:263-268.
Johnsson, M. 1988. Evaluation of the consensus conference program in Sweden: Its
impact on physicians. International Journal of Technology Assessment in Health
Care 4:89-94.
Representative terms from entire chapter:
development conferences
