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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 93
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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.