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OCR for page 110
Profile of the Consensus Development
Program in The Netherlands:
National Organization for Quality
Assurance in Hospitals (CBO)
Nick S. Klazinga, Anton F. Casparie, and
I. I. E. van Everdingen
NATIONAL CONTEXT
The origin of the CBO (Centraal Begeleidingsorgaan voor de In-
tercollegiale Toetsing, or National Organization for Quality Assur-
ance in Hospitals) consensus development process lies in the quality
assurance activities of medical specialists in hospitals (Klazinga et
al., 19881. In the early 1980s, it became evident that it was difficult
to develop criteria for audit studies at the hospital level for several
controversial medical topics. The development of guidelines for
medical practice on a national level was needed. In 1981, the Scien-
tif~c Council of CBO decided to start a consensus development pro-
gram similar to the one conducted by the National Institutes of Health
in the United States. CBO is an independent nonprofit organization
founded in 1979 by the Dutch Specialists Association and the Asso-
ciation of Medical Directors. The Scientific Council of CBO repre-
sents all 34 scientific medical associations in The Netherlands. The
purposes of the CBO consensus development program are (~) to
establish guidelines on controversial medical issues and (2) to en-
sure the quality of care by promoting behavioral change among
medical practitioners (Casparie and van Everdingen, 1985a, b).
The primary goal of the consensus development program is to
develop guidelines for daily medical practice such that they not only
~10
OCR for page 111
NE~ERIANDS CBO
1.11
represent the state of the art but also are acceptable to the medical
community. The program is run for and by the profession itself
(scientific associations), but finds recognition among financiers,
government authorities, and patients' organizations. In recent gov-
ernment policy papers, consensus development is mentioned as one
of the profession's contributions to quality assurance. The clini-
cians (specialists, general practitioners, nurses, physiotherapists, etc.)
are the intended primary users of the consensus statements; how-
ever, recommendations may also be of interest to hospital adminis-
trators and policymakers (Casparie et al., 1987~.
There are usually four conferences each year with an average
attendance of 300 individuals per conference. The total yearly cost
of the program is approximately OFF. 400,000 (U.S. $200,000~. This
includes costs for personnel, materials, meeting arrangements, over-
head, etc.
SCOPE OF THE PROGRAM
The program assesses selected clinical problems. The choice of
technology to be assessed depends on the problem in question: Drugs,
devices, medical or surgical procedures, support systems, and organ-
izational or administrative systems may be examined. Technologies
for discrete stages of intervention are discussed for different clinical
conditions; for example, prevention of bedsores, diagnosis of deep
venous thrombosis, and treatment for osteoporosis (van Everdingen
and Caspar~e, 19XX; van Everdingen et al., 1988~. Table ~ lists the
CBO consensus development programs that have taken place over
the years. Some of the technologies assessed are new (used only by
practitioners in university hospitals) or already established and/or
widespread. Some have been labeled as obsolete during the process
of consensus development.
The properties of a technology that are normally addressed are
safety, efficacy, effectiveness, and, to a lesser extent, cost-effective-
ness and service requirements. Suggestions for consensus develop-
ment topics come from scientific associations, peer review commit-
tees in hospitals, or medical foundations such as The Netheriarlds
Heart Foundation (consensus on cholesterol). The Scientific Coun-
ci} of CBO is responsible for final selection of topics.
OCR for page 112
112
CONSENSUS DEVELOPMENT
TABLE ~ CBO Consensus Development
Program
Year Program
1982 Blood transfusion therapy
1983 Traumatic lesions of the back
Mammography policy
1984 Severe brain damage
Melanoma of the skin
Thrombocyte transfusion policy
1985 Solitary thyroid nodules
Prevention of bedsores
Osteoporosis
Foot problems of diabetic patients
1986 Diagnosis of deep venous thrombosis
Nonscrotal testis
Treatment of bedsores
Drug addicts in prison
Hypercholesterolemia
1987 Prevention of herpes neonatorum
Hemophilia
Follow-up colon polyps
Cholesterol
Suspect lymph nodules in the neck
Diagnosis of atopic syndrome
Total hip joint replacement
Follow-up of colorectal cancer
1988 Diagnosis of dementia
Sports and cardiac pathologies
1989 Prevention of deep venous thrombosis
Prevention of hospital infections
1990 Diagnostics for lung carcinoma
Hypertension
Acute otitis media
Nutrition and allergy
1991 Cerebrovascular accident
Diabetic retinopathy
Treatment of deep venous thrombosis
OCR for page 113
NETHERLANDS CBO
The following criteria are applied in the choice of topics:
· controversial in the literature and among practitioners
· relevant in terms of health benefit
· feasibility of consensus development
· relevant for medical practice
· sufficient scientific data available.
FORMAT AND CONDUCT OF THE PROCESS
113
The consensus development process requires about two years. First,
a topic is selected by the Scientific Council of COO, and then a
suitable chair is selected for the working group. Formation of the
complete working group takes about three months. All members of
the working group are experts and official representatives of their
respective scientific associations. Representatives from the fields of
nursing, physiotherapy, and general practice are invited to partici-
pate as needed. During the following 12 months, the working group
meets six to ten times to develop a syllabus with background infor-
mation and to draft consensus statements.
The consensus development conference takes place after comple-
tion of the draft statements by the working group. All practitioners
and interested persons can attend the conference; attendance has
ranged from 150 to 1,000 individuals. The conference itself lasts
one to two days. Two weeks in advance of the conference, partici-
pants receive the syllabus with background information and drafts of
proposed consensus statements. AR statements are defended by the
working group as a whole. After each presentation, there is ample
time for questions; later in the program the audience may comment
on the draft consensus statements. Considerable time is allocated
for discussion between members of the audience and members of the
working group. At the end of the day, the chair summarizes the
results and tries to formulate a definite set of consensus guidelines.
The chair asks the audience explicitly whether they agree with the
consensus text, and then he closes the meeting. One month after the
consensus development conference, the working group meets for the
last time to finalize the text of the consensus statement for publica-
tion.
OCR for page 114
114
DOCUMENTATION AND USE OF EVIDENCE IN
CONSENSUS DEVELOPMENT
CO]VSE NSUS DEKELOPME~
The information used during the consensus development process
comes from the experts in the working group. Sometimes, formal
literature searches are performed on a small scale, but in most cases
the experts bring in literature as well as their own material. The
working group may use reports of clinical trials, epidemiologic stud-
ies, and literature reviews for particular topics (Klazinga et al., 1987~.
The available evidence was weighed systematically on several occa-
sions according to the memos proposed by Sackett during the Na-
tional Institutes of Health conference on the prevention of venous
thrombosis and pulmonary embolism, March 24-26, 1986 (Sackett,
1986~. On other occasions, the evidence collected from the litera-
ture and the experts' experience was combined. In the syllabus
written by the members of the working group, reference is made to
the data used during the consensus development process. The most
important literature is also mentioned in the text of the final consen-
sus statement.
DISSEMINATION AND IMPACT
CBO consensus development conferences are widely announced
to reach physicians in The Netherlands via professional journals and
direct mailing to the appropriate specialty groups. Announcements
are posted in hospitals to attract attention. The final consensus
statements are published in the Nederiands Tij~schrift boor
Geneeskunde (a Dutch medical journal); and copies are sent to those
who attended the conference as well as all medical staff, hospital
administrators, and chairpersons of peer review committees. Scien-
tif~c associations that cosponsor the consensus development confer-
ence sometimes send the consensus results to their members. The
text can be purchased from CBO, and the CBO staff is also active in
disseminating the consensus reports to hospital practitioners who are
involved in quality assurance. In a few cases, follow-up meetings
have been held for specialists who were unable to attend the consen-
sus development conference.
The consensus statements are intended to change clinical practice
by altering physician behavior. This is why CBO works for large-
scale commitment and involvement of medical specialists in the
OCR for page 115
NEI~ERL4NDS CBO
115
consensus development process. Although the consensus guidelines
have no legislative bearing, they acquire status from the involve-
ment of the different scientific associations and experts. The CBO
consensus development program has been evaluated in terms of both
process and effect (van Everdingen, 1988~. Evaluations have ad-
dressed:
· the consensus meeting process and the activities in the working
groups
· impact of awareness of consensus guidelines among medical
practitioners
· impact of consensus guidelines by practitioners (formulation of
protocols and criteria setting for audit studies in hospitals)
· effects of consensus guidelines on the behavior of medical spe-
cialists (on the hospital and national levels).
The evaluation activities of CBO are summarized in Table 2.
REFERENCES
Casparie, A.F., and J.J.E. van Everdingen. 1985a. Consensus development in The
Netherlands. European Newsletter on Quality Assurance 2:1, 5.
Casparie, A.F., and J.J.E. van Everdingen. 1985b. Consensus development confer-
ences in The Netherlands. International Journal of Technology Assessment in
Health Care 1~4~:905-912.
Casparie, A.F., N.S. Klazinga, J.J.E. van Everdingen, and P.P. Touw. 1987. Health-
care providers resolve clinical controversies: The Dutch consensus approach.
Australian Clinical Review 7~24~:43-47.
Klazinga, N.S., A.F. Casparie, and J.J.E. van Everdingen. 1987. Contribution of
medical decision-making to consensus development conferences. Health Policy
8:339-346.
Klazinga, N.S., A.F. Casparie, and J.J.E. van Everdingen. 1988. Quality assurance
on the crossroad of medical decision making and management of the health care
process in the hospital (abstract). Theoretical Surgery 3:4243.
Sackett, D.L. 1986. Statistical issues in clinical trials. Pp. 3640 in Program and
Abstracts for the NIH Consensus Development Conference on the Prevention of
Venous Thrombosis and Pulmonary Embolism. Bethesda, Md.: Office of Medi-
cal Applications of Research.
van Everdingen, J.J.E. 1988. Consensusontwikkeling in de Geneeskunde. Thesis
(English summary). Utrecht, Bonn: Scheltema & HoLicema.
van Everdingen, J.J.E., and A.P. Casparie. 1988. Consensus development confer-
ences on osteoporosis (letter to the editor). British Medical Journal 296:61-62.
van Everdingen, J.J.E., N.S. Klazinga, and A.F. Casparie. 1988. Blood transfusion
policy in Dutch hospitals. International Journal of Health Care Quality Assur-
ance 1:16-19.
OCR for page 116
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Representative terms from entire chapter:
van everdingen
