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OCR for page 93
Profile of a Consensus Development
Program in Canada:
The Canadian Research Group
Jonathan Lomas
NATIONAL CONTEXT
The Canadian Research Group consensus development program
has no particular national context, as it is a group of interested
researchers who engage in opportunistic consensus development to
undertake research on the consensus development process. The group
consists of individuals from McMaster University and the Univer-
sity of Toronto in Ontario and the University of British Columbia in
Vancouver. The program obtains funding through peer review grant
applications and not in connection with any ongoing program funds.
The cost of conducting the consensus development exercises is ap-
proximately $70,000-$ ~ 00,000 (Canadian).
The underlying objective of our consensus development program
is to translate existing research evidence into clinical practice. The
principal audience is, therefore, practicing clinicians. It may be,
however, that consumers and/or funding agents in the system are
useful targets. The ultimate goal of the program is to change clini-
cal practice where it has been demonstrated to be inappropriate.
SCOPE OF THI: PROGRAM
The scope of the program is quite limited, as it is primarily a
vehicle for research. We have been opportunistic in choosing our
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94
CONSENSUS DEVEL(:)PMENT
topics; thus, we have selected topics for which (~) there is some
evidence of a lack of congruence between the research evidence and
clinical practice and (2) we have obtained some support for the
project from a specialty society or a group of physicians. To date,
we have conducted two consensus development conferences: the
appropriate use of cesarean section (in conjunction with the Society
of Obstetricians and Gynecologists of Canada) and priority-setting
among candidates for coronary artery bypass surgery (with an inter-
ested group of cardiovascular surgeons and cardiologists).
The conferences address the effectiveness of clinical services almost
exclusively. The programs do not consider cost-effectiveness or ser-
vice requirements. In some cases, ethical, legal, and social implica-
tions come to play a role in the development of consensus.
FORMAT AND CONDUCT OF THE PROCESS
The entire consensus development process takes 6 to 15 months,
depending on the urgency and the availability of staff and research
funds. During the first stage, the researchers identify priority areas
by analyzing existing administrative data sets in health care. The
assessment areas which, at first pass, do not appear to be congruent
with existing research evidence are highlighted. During the next
stage, the researchers identify a pane} of individuals, most of whom
are clinicians but not all of whom are from the specific clinical area
under investigation. An attempt is made to include epidemiologists
on the panel. The two most important elements of the process are
(~) the preparation of a comprehensive background paper on exist-
ing research evidence for the area under discussion, with clear con-
sideration of the methodologic quality of the evidence, and (2) the
completion by panelists of indications questionnaires. The indica-
tions questionnaires consist of representative scenarios for the clini-
cal conditions under study. The panelists rate the scenarios accord-
ing to their appropriateness for intervention (similar to the RAND
Colporation technique). Speakers or witnesses do not necessarily
make formal personal presentations, although the panel does meet
on two occasions to consider the question under study. During the
first meeting, the pane} develops an interim idea for the statement
followed by dissemination and discussion of the resulting document.
The second and concluding meeting, which may be done through the
mail, is held to complete the statement.
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CANADIAN RESEARCH GROUP
DOCUMENTATION AND USE OF EVIDENCE IN
CONSENSUS DEVELOPMENT
95
Staff are hired specif~caBy to undertake comprehensive literature
reviews, with substantial attention given to the methodologic quality
of the various studies. The results of the literature review are pre-
sented in a format that focuses on the high-methodologic-quality
studies as opposed to the low-methodologic-quality studies. The
thrust of the consensus development exercise is to make scientific
evidence outweigh expert opinion when data are available.
DISSEMINATION AND IMPACT
The Canadian Research Group is particularly interested in the
dissemination and impact of the consensus development statement.
Dissemination has occurred by publication in journals and some tar-
geted mailing to specialists who will be affected by the statement.
The active attempts to implement the statement are, however, poten-
tially more important than this passive dissemination process. The
research group is currently conducting a large randomized controlled
trial to evaluate different ways to assess the value of two alternative
implementation strategies for consensus recommendations in com-
munity hospitals. One strategy involves local educational influen-
tials (individuals identified by their local colleagues); the other strat-
egy focuses on the use of chart audit and data feedback. The results
of this evaluation are not yet available but should be available in
1990.
In the meantime, the research group has evaluated the impact of
the first consensus development statement (cesarean section) on the
basis of its passive dissemination. The statement had an impact on
clinicians' attitudes and self-reported practices. The impact on their
knowledge is less marked, and the impact on their actual practice, as
measured by hospital discharge data, is minimal, although statisti-
cally significant (L`omas et al., 1989~.
REFERENCES
Lomas, J., G.M. Anderson, K. Domnick-Pierre, E. Vayda, M.W. Enkin, and W.J.
Hannah. 1989. Do practice guidelines guide practice? The effect of a consensus
statement on the practice of physicians. New England Journal of Medicine
321: 1306-131 1.
Representative terms from entire chapter:
canadian research
