Improving Consensus Development for Health Technology Assessment An International Perspective (1990) / Chapter Skim
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Format and Conduct of Consensus Development Conferences: A Multination Comparison
Format and Conduct of Consensus Development Conferences: A Multination Comparison
Pages 32-68
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McGlynn, Jacqueline Kosecoff, and Robert H Brook INTRODUCTION The purpose of this paper is to compare the methods used in nine countries to organize and conduct consensus development conferences on scientific issues related to the delivery of medical care.
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. The consensus development conference is a complex entity, and researchers have undertaken scientific evaluations of the conferences and their impact in their respective countries (Calitorp, 1988; Johnsson, 1988; Kanouse et al., 1989; Lomas et al., 1988; Worunan et al., 1988~.
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Profiles prepared by representatives from each country for the June 1989 workshop on international consensus development for medical technology assessment organized by the Institute of Medicine 2. Published articles and consensus statements related to such conferences 3.
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The evidence that is available in any particular area limits the issues that can be addressed. Most consensus development conferences address issues of effectiveness and efficacy (the strength of the clinical literature)
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No. of topics Health professionals; public Benefits; appropriate use of technology; future research Instituteg within NIH and OMAR 75 Practicing primary .
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of Briush Columbia) 2 6 3 37 Public; health planners; health professionals Effecuiveness; safety; adoption level; economic, organi7~honal, and ethical implications Subcommittee of Danish Research Council Health care providers; researchers; public, providers of agricultural products (cholesterol)
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efficacy, efficacy; efficacy; effectiveness; risks; effectiveness; also: cost- costs; cost/economic effectiveness, consequences: implications; service requirements organizational, minor role for psychologicaVsocial, ethical, legal, ethical social implications Who selects Scientific Council Technology Representatives from topics? of COO Assessment Medical Research Committee Council and Swedish Planning end Rationalization Institute of Health Services form a steering committee No.
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of Health 7 Degree of Variation among Countries Six focus on health professionals; one on public two on national politics or planners; United Kingdom considers all potential audience groups to be equally important Scope varies: most have global perspectives; few seem likely to truly address efficacy; four examine appropriateness; one examines whether technology is a replacement or ~ . substitute Most combine government and specialty society input (except United States and Canada II)
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address appropriateness of technology use. Topic Selection Most countries rely upon a combination of government and specialty societies to select topics for consensus development conferences.
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members receive introductory textbook-type information (necessary for the lay members of the panel) as well as a comprehensive set of readings, drawn from a computer search of all relevant literature, and abstracts prepared by the expert speakers who will present information at the actual meeting.
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paper abstracts sent clinical trials or in advance; epidemiologic studies; sometimes background quality of evidence reports prepared or is graded; expert summaries of expert opinion used state of science; if no evidence is BE coordinator detennines available scope of literature search Is there a review of For sane topics, Some efforts made to current clinical cum nt uses are measure patient practice (e.g., summarized compliance; efficacy, current working on rules for uses of die using data on technology)
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. prep Plenary responses to questions; efficacy considered throughout Prepared responses to questions was attempted Ally once (for OhtiS media)
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and studies, expert literature reviews compilation presentations; have been done; of scientific abstracts sent in evidence graded evidence (abstracts advance using Sackett of expert method; background testimony) papers use research plus clinical experience Is there a review of Ad hoc study before Experts asked to current clinical conference to present data on practice (e.g., document spread actual state of - efficacy, current and use of technology, practice uses of the cost, and health technology)
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Data on magnetic resonance imaging was collected for one year through a registry Partially, although no validation or controlled trial data available 9-12 months Planing committee nominated by King's Fund Reading material sent to panel before the conference includes introductory texts, actual literature, and 1,000 word abstracts from speakers Small surveys done where relevant; experts asked to present data Where available Most seem to take about a year Two have staff; seven have working groups; one has a consensus panel Three have formal synthesis; three have oral testimony; one has bibliography; seven have abstracts sent in advance; one has reading material Six rely on expelt testimony; one asks panelists to use experience; one uses review in planning conference; four conduct special surveys Six use outcomes to some degree (usually based on availability) ; Ihe Netherlands working on incorporating patient outcome data through decision analysis techniques Specific questions Advance preparation Five have prepared 6 months of questions or recommendations in before conference; statement advance; six have draft of statement specifically questions in advance; prepared 2 weeks disallowed two have no advance before conference preparation; one has patient indications 45
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Most consensus statements do not refer to the literature upon which findings are based, which makes it difficult to determine whether and to what extent He literature has had an influence on the conference's conclusions and whether some literature is more influential than other. Most countries indicate that
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An evaluation of the U.S. experience, however, demonstrated that conference topics and subsequent recommendations addressed issues, such as the discontinuation of Halstead radical mastectomies, that were largely obsolete in clinical practice prior to the actual conference (Kosecoff et al., 1987~.
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, some form of draft consensus statement is prepared in advance and is made final during the conference. Canada ~ uses an entirely different approach from the rest of the countries; it relies on a permanent pane} that is responsible for an ongoing process of writing papers evaluating the use of certain preventive measures and diagnostic procedures used in peri
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based on deliberations at regularly scheduled pane} meetings; as long as two years may be spent on the preparation of these statements. In The Netherlands, panelists receive the draft consensus statement in advance of the meeting.
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Background of the panel members? 9-16 Director of sponsoring BID with advice from the planning committee Stature in field · .
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; balanced researcher, skill in conducting meetings Planning committee Researchers; .
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practitioners, physiotherapists Half medical experts; half nonmedical experts (health economists, ethicists, lawyers, joumalists, health administrators, health politics) ; neutral Half medical experts; half from health, care profession economists, policy, epidemiologists, · .
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King's Fund and planning committee Two specialists in topic; half medical (not technology users) ; half nonmedical (judicial model)
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In one conference in Me United Kingdom, the panel chair was deliberately selected from a specialty that does not use the technology being evaluated (e.g., a neurosurgeon chaired the coronary artery bypass panel)
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mode! of conferences meeting times, which last two and a half days, during which the pane} writes or modifies the consensus statement in an all-night session starting on the second day.
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What criteria are used for making decisions? Two and a half days (including nights)
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FORMAT AND CONDUCT 57 Canada II Denmark Finland Indications rated for awropnateness, inappn~iateness, and equivalent uses of technology and consensus statement Two and a half days Presentations on unpublished data from 11 experts All work done in private meeting to produce an interim consensus statement Consensus statement Three days Public sessions on all three days; audience may ask questions; audience: 150 Expert group and panel meet night before; panel meets evening of first day; consensus statement prepared in closed session Unanimity Panel Questioning panel Panel Yes No No Benefit > risk None None Companson of Public debate in Not clear ratings indicates newspapers and level of agreanent professional journals after dissemination of results Voting is done Not clear Not clear anonymously; opinions known before panel chair can ensure these are brought up Consensus statement Two and a half days (including nights) Two days of plenary sessions with medical community, expert witnesses, public; audience: 15~160 One to two meetings before conference is held; meet night before plenary session Table 4 continues
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audience: 150-1,000 Consensus statement Consensus press conference statement Two and a half days Two and a half days (through night on last day if necessary) Physicians, experts and public audience: ~200 One and a half days for expert Private panel Experts meet several Private sessions to Panel starts writing sessions?
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; many hold press conference to release statement Most are two and a half days and write through night Canada I is four to eight iterations over one to two years One day of evidence; Same as NIH; All except Canada I half day of discussion; audience: 200 rely on public foam audience: 150 Two half-day Executive session All write statements executive sessions; for writing in executive session; meet night before statement; some Canada II has plenary session revisions made after indications rated before public presentation and during meeting No formal voting; No clear definitions No clear definitions comments on draft Chairman Panel Panel makes decision in all but one case; public input in two; chairman decides in Switzerland No No No, except Canada II Value of scientific None evidence; confonnity with state of practice Detailed discussion; Not clear if no consensus, disagreement mentioned in final document Little experience handling Not clear problems in a nonhomogeneous group; panel did not question experts thoroughly Generally no .
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Sessions The bulk of work required to answer questions and to draft, revise, and complete the consensus statement is done in private sessions. Most panels meet the night before the conference begins to receive instructions about the process of the meeting itself and to hear We `'charge" to the panel (i.e., questions to be answered)
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are responsible for formulating guidelines to define consensus, but whether that requirement introduces any more systematic consideration into the process is unclear. Most countries release consensus statements at press conferences and/or in journals, which presumably allows a forum for dissenters to present their opinions.
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Link between Goals and Inputs Most countries indicate that they use consensus development conferences to address a variety of issues, including the safety, effectiveness, efficacy, appropriateness, and consequences (political, social, ethical) of medical care and technology.
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Finally, linking of each consensus statement to its supporting evidence would allow users of the consensus findings to understand the scientific bases for the recommendations and would make clear where judgments are based on clinical trials, epidemiological studies, observational studies, or expert opinion. This might also enable panels
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The most straightforward way of introducing this type of definition of consensus into the process is by taking formal votes throughout the development of the consensus statement. Voting also provides a mechanism that allows for disagreement without necessarily endangering the overall process.
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Writing the Consensus Statement Most countries appear to use the U.S. model when the panel writes the statement in an overnight session and presents the results the next morning.
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Along with the literature review prepared in advance, some countries begin drafting the consensus statement before the meeting, giving panelists the opportunity to consider the issues and focus on those areas of particular disagreement or controversy. The Canada IT method developed at RAND/UCLA, for example, requires that panelists rate indications for the appropriate use of a procedure in advance using a modified Delphi method.
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Such formal mechanisms as voting or polling, whether done anonymously or not, may allow for more controversial issues to be considered. Finally,~ me current proclivity toward writing the consensus statement in an all-night session seems to be unnecessarily grueling and may have a negative effect on the final product.
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1985. First consensus development conference in United Kingdom: On coronary artery bypass grafting, views of audience, panel, and speakers.
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