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Profile of a Consensus Development Program in Canada: The Canadian Task Force on the Periodic Health Examination Renaldo N. Battista NATIONAL CONTEXT The Canadian Task Force on the Periodic Health Examination was created in 1976 by the Conference of Deputy Ministers of Health, with a mandate to examine the scientific merit of the annual checkup and to determine how periodic health examinations might enhance or protect the health of the population. The work of the task force was and continues to be funded by the National Department of Health and Welfare (federal government). However, the membership is composed of individuals who are not directly linked to the govern- ment and who have academic affiliations. The task force reviews the scientific evidence regarding the effec- tiveness of preventive services that are to be offered to asympto- matic individuals within primary health care settings. The sum of the evidence about whether a clinical procedure can be expected to be of benefit to the population as a whole is synthesized, and prac- tice policy recommendations are formulated. The recommendations were originally targeted to practicing pr~- mary care physicians; but we now recognize the importance of ad- dressing medical educators, policymakers, and the general public as well. The recommendations of the task force do not carry formal legal or legislative weight; they are simply practice guidelines to be used as a reference by health care providers, policymakers, and 87

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88 CONSENSUS DEVELOPMENT medical educators. They may be used as guidelines for reimburse- ment of medical services, but the impact of making preventive ser- vices explicitly reimbursable has been minimal. The Canadian Task Force on the Periodic Health Examination has an annual budget of approximately $100,000 (Canadian) for consen- sus development activities. For the past three years, the government has provided half of this amount as a supplemental fund for a full- time research coordinator; the rest of the funds are used to conduct and support three to four meetings each year. The process is rela- tively inexpensive, partly because panel members are asked to use their own resources to produce documents. The task force assumes responsibility for the purchase and dissemination of reprints. SCOPE OF THE PROGRAM The task force assesses the appropriateness of applying specific clinical procedures for the prevention of adverse health outcomes. The emphasis is on clinical procedures that can be carried out in the primary care setting; they may be physical examinations, laboratory tests, vaccinations, or counseling activities. In the case of primary prevention, where the goal is to prevent the initiation of the disease process, the technology applied might be a vaccine or an interven- tion such as counseling and patient education. In the case of sec- ondary prevention, the goal is to detect a disease process before it becomes symptomatic in order to apply therapy when it will have a greater impact on the progress of the disease or to detect a risk factor for disease. In the case of secondary prevention, we would evaluate not only the early detection procedure (physical examina- tion or laboratory test) but also the diagnostic and treatment inter- ventions. The focus of the task force is on preventable conditions rather than the clinical procedures themselves. For instance, rather than focusing on the efficacy of the digital rectal examination, we exam- ine the evidence on He preventability of prostate cancer by all pro- cedures reviewed in the literature, including per-rectal ultrasound, laboratory tests, and the digital rectal examination. In choosing which procedures to consider for review, however, we choose tech- niques that can be expected to have an impact on clinical practice in the present or in the very near future that is, new or established technologies.

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CANADIAN TASK FORCE ON THE PERIODIC lIEALTH EXAMINATION 89 We are primarily interested in the effectiveness of the application of a clinical procedure; that is, does this procedure net more benefit than harm in those to whom it is offered? When there is no evidence as to its effectiveness in the real clinical situation, we then examine its efficacy, (i.e., its ideal benefit-to-harm ratio). However, this is not the sole basis for our recommendations; we also consider safety; acceptability to the patient and provider; cost-effectiveness; and ethi- cal, psychological, or legal implications. Only conditions that have a potential for prevention are consid- ered. Whether the condition carries a considerable burden of suffer- ing is another important criterion for its choice; this burden may be quantitative (e.g., mortality, morbidity, years of life lost) or qualita- tive (e.g., perception by the public as being of concern). We may also choose to consider a condition with respect to a given technol- ogy when it is associated with high costs or when it has other im- pacts on clinical practice. An example of this would be the evalu- ation of intrauterine electronic fetal monitoring during labor (Bat- tista and Fletcher, 1988; Canadian Task Force on the Periodic Health Examination, 1979~. FORMAT AND CONDUCT OF THE PROCESS The task force is composed of a stable pane! of members who are well versed in the clinical epidemiologic approach and who possess expertise in their own fields of pediatrics, family medicine, psychia- try, infectious diseases, geriatrics, and nursing. Various conditions will be under consideration at any one time, and each member will be responsible for reviewing the scientific evidence of one condi- tion. Our process is iterative in that members undertake an over- view of the literature, prepare a background paper, present it to the task force for discussion, modify the paper or literature review based on the feedback, present a new draft at the next meeting, and so on, until the entire task force is satisfied with the extent of the review and comes to a consensus on the implications of the evidence for clinical practice. Depending on the complexity of the condition, arriving at consensus requires from four to eight iterations spread over one to two years. Background papers are distributed to the members before the meetings, and approximately one hour is allo- cated to a discussion of each condition at each meeting. Formulation of recommendations for practice are reached by con- .

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9o CONSENSUS DEVELOPMENT sensus. The recommendations are primarily based on the value of the scientific evidence according to predetermined criteria. These criteria are primarily based on the value of the scientific evidence according to the quality of study design, study execution, and re- porting. In cases where the scientific evidence is clear and the task force is reassured that ad pertinent studies have been considered, consensus is easily reached. When the evidence is poor or equivocal, the recommendation is made on other grounds such as cost, ethics, or safety considerations. Since this evidence rests primarily on the opinions of experts, the achievement of consensus is more difficult and may require several iterations. After consensus is achieved, the task force's position is often sent to an expert in the field for peer review before it is published in English in the Canadian Medical Association Journal (Canadian Task Force on the Periodic Health Examination, 1979, 1984, 1986, 1988, 1989) and in French in L'Union Medicate du Canada. These medical journals have a combined total circulation of 65,000, reaching almost all of the physicians in Can- ada. DOCUMENTATION AND USE OF EVIDENCE IN CONSENSUS DEVELOPMENT As mentioned previously, each member prepares a background paper that is circulated to other members before the meetings. Only original reports of clinical trials and epidemiologic studies are con- sidered; these are identified from computerized MEDLINE searches, key citations, and consultations with experts in the field. The qual- ity of the evidence from each study is always given priority in the consensus development process; expert opinion is only invoked in the absence of evidence. The background paper is condensed to include only the key infor- mation and key references pertaining to the decision; this concise statement appears in the medical journals. Currently, the task force is moving toward formal documentation of its decision-making pro- cess so that each recommendation can be traced. This will probably not be published, but will be made available to interested parties. DISSEMINATION AND IMPACT Task force meetings are held on a regular basis three times per year. Only members and others who act as consultants participate in

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CANADIAN TASK FORCE ON 771E PERIODIC HEALTH EXAMINATION 91 these meetings, so wider notice is not given. It is a closed process; neither the agenda of the conditions being discussed nor the interim statements are made available to the general public, although repre- sentatives from the Department of Health and Welfare are notified of all developments. The intended impact of the task force recommendations is to change clinical practice and enhance provider knowledge (Battista and Micka- lide, in press). The recommendations are published in the Canadian Medical Association Journal and L'Union Medicale du Canada, and reprints are sent to those on a growing list of people who have expressed interest in the task force's work. Since the task force released its first report in 1979, there have been significant changes in clinical practice that are compatible with our recommendations, but it is difficult to make a causal link with the task force recom- mendations. One measure of impact is the request for reprints of our reports; more than 40,000 requests for the 1979 report have been received from people from all over the world. The work of the periodic health examination task force is widely quoted in the lay press, and in academic circles it has been used in curriculum design and as a standard for preventive behavior. The consensus process of the task force has not been evaluated formally or informally. How- ever, a study of general practitioners that was conducted in Quebec and New Brunswick three to four years after the first task force report was presented documented the varying level of integration of some preventive activities into clinical practice and witnessed the need forimprovement(Battista, 1983; Battista and Spitzer, 1983; Battista et al., 1985). REFERENCES Battista, R.N. 1983. Adult cancer prevention in primary care: Patterns of practice in Quebec. American Journal of Public Health 73(9):1036-1039. Battista, R.N., and S.W. Fletcher. 1988. Making recommendations on preventive practices; methodological issues. American Journal of Preventive Medicine 4 (4~(Suppl.~:53-67. Battista, R.N., and A.D. Mickalide. In press. Integration of preventive services into primary care a conceptual framework for implementation. In Preventing Dis- ease: Beyond the Rhetoric, R. Goldbloom and R.S. Lawrence, eds. New York: Springer-Verlag. Battista, R.N., and W.O. Spitzer. l9B3. Adult cancer prevention in primary care: Contrasts among primary care settings in Quebec. American Journal of Public Health 73~9~:1040-1041.

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92 CONSENSUS DEVELOPMENT Battista, R.N., C.S. Palmer, B.M. Marchand, and W.O. Spitzer. 1985. Patterns of preventive practice in New Brunswick. Canadian Medical Association Journal 132: 1013-1015. Canadian Task Force on the Periodic Health Examination. 1979. The periodic health examination. Canadian Medical Association Journal 121:1193-1254. Canadian Task Force on the Periodic Health Examination. 1984. The periodic health examination: 2. 1984 Update. Canadian Medical Association Journal 130: 1278-1285. Canadian Task Force on the Periodic Health Examination. 1986. The periodic health examination: 2. 1985 Update. Canadian Medical Association Journal 135:724-727. Canadian Task Force on the Periodic Health Examination. 1988. The periodic health examination: 2. 1987 Update. Canadian Medical Association Journal 138:618-626. Canadian Task Force on the Periodic Health Examination. 1989. The periodic health examination: 2. 1989 Update. Canadian Medical Association Journal 141:2()9-216.