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Institute of medication (US) council on Health treatment Technology; Goodman C, Baratz SR, editors. Improving Consensus development for Health modern technology Assessment: An worldwide Perspective. Washington (DC): nationwide Academies press (US); 1990.
Improving Consensus advance for Health an innovation Assessment: An international Perspective.Show details
Arnold D. Kaluzny
Consensus development conferences to be initiated in the United claims at the national Institutes of wellness (NIH) in 1977 together a technique for developing a declare of welcomed standards because that clinical practice either through regard come the usage of a details technology or the treatment of a particular condition or syndrome. Other countries have organized conferences, although your formats and also purposes have changed over time and also between countries. The purpose of this file is to take into consideration the main aspects of the dissemination tasks in miscellaneous countries" programs, to think about different techniques of diffusion, and to assess their impacts in assorted settings. The analysis presented is based upon program profiles ready by each nation for the global Workshop ~ above Consensus advancement for Medical technology Assessment (1989). A comparative evaluation of these profiles gives a distinctive opportunity to analyze international initiatives in the circulation of consensus recommendations and to suggest possible areas for more research.
Elements of dissemination Activities
While the aspects of the dissemination process for any certain program differ by country, the is possible to compare these vis-à-vis barriers to diffusion established by currently theory and research. Although the list could be quite extensive, attention will certainly be offered to four determinants with varying levels of tractability that may straight influence dissemination activities: qualities of the technology under review and the resulting agreement statement, adopter characteristics, ecological constraints and also incentives, and also communication channels.
The modern technology selected for review and also the technological attributes taken into consideration are important factors of dissemination. Unfortunately, the literary works on the diffusion that medical modern technology is often defined by inconsistent findings and thus is often discounted in our in its entirety effort to far better manage the review procedure and the circulation of cutting edge technology. In part, this inconsistency is accounted because that by what some researchers (Downs and Mohr, 1976) have actually termed a unitary method to developing innovation theory. This means that every innovations, nevertheless of kind and/or specific attributes, are considered as equal and subject to the same theory. Increasingly, that is known that both the rate and speed of fostering and diffusion space a role of the interaction of the type and characteristics of the development with miscellaneous adopter qualities (Fennell and Warnecke, 1988). Moreover, over there is some proof to suggest that both diffusion and adoption of various types of program or technologies are not totally random. There appears to it is in a predictable order that the adopting unit adheres to as it have tendency to carry out and/or take on a details activity (Fennell, 1984). Certain types of technologies might be attached in together a way that the implementation the one has tendency to facilitate implementation of another. Thus, the choice of topics because that consensus and also the range of criteria upon which judgments room made are extremely essential in the design of a dissemination strategy.
A evaluation of consensus development conferences indicates that they take it a fairly inclusive see of the varieties of modern technology subject to the consensus breakthrough process. While every programs point out criteria for inclusion, the technologies reviewed have tendency to be reasonably eclectic and not topic to any apparent a priori strategy that would facilitate dissemination. Among the programs thought about here, the one exemption to this generalization is the Canadian Task pressure on the Periodic health Examination. The Canadian task Force borders the emphasis of their evaluation and dissemination efforts to preventive services available to asymptomatic people within a primary treatment setting. This implicit programmatic theme might facilitate dissemination and the subsequent adoption of consensus recommendations by physicians.
Different countries assess a range of attributes for particular technologies in the consensus breakthrough programs. As recorded in the development literature (Fineberg, 1985; Scott, in press), these features influence diffusion of an innovation as well as the capacity to have an affect on medical professional practice. For example, modern technologies that have a favorable cost-benefit ratio, space compatible with ongoing practice patterns, and also are constant with reimbursement policies will it is in disseminated much more readily to potential adopters. Table 1 gift the various attributes upon which technologies room assessed follow to three major groupings. The U.S. Program and also the Canadian Research team focus explicitly and nearly exclusively top top the performance of technology. The Canadian job Force and also The Netherlands emphasize effectiveness, with an additional consideration offered to the psychosocial, economic, ethical, and also legal implications. The programs in Finland, Norway, Denmark, the joined Kingdom, and also Sweden show up to provide equal weight to effectiveness and other attributes, consisting of cost and also service requirements.
Technology and its associated attributes space important components in the diffusion process, yet an equally critical element concerns the qualities of the agreement statement itself. Exactly how clear is the statement? Is that prescriptive or discursive, and also does it carry out concrete and particular actions or guidelines that physicians deserve to follow in clinical practice? if there has been no systematic research of just how the attributes of the agreement statement affect physician decision making, one U.S. Examine of the NIH consensus development procedure attempted to assess the features of the agreement statement (Kanouse et al., 1987). The researchers selected 24 declaration for evaluation and uncovered three dimensions for statement classification: discursive, didactic, and scholarly. Discursive statements often tend to be long and abstract and also contain few recommendations. Consensus statements identified as didactic offer clinicians practical and detailed guidance, while scholarly statements offer up-to-date explanation of the scientific proof bearing top top a topic and also devote an ext attention to detail than many statements. The vital issue is clearly the relationship of these and other attributes to an actual adjust in doctor knowledge and also behavior.
Adopter Characteristics—Behavior and Structure
Physician characteristics and also the paper definition of their practice are an important to any dissemination effort. Table 2 indicates that several countries have conducted evaluations of your programs and that the level that awareness of both the conferences and their content vary by country and within nation by doctor characteristics. For example, evaluation results suggest that there are far-ranging differences in the level the awareness in between U.S. And also Swedish physicians. In Sweden, a national sample of doctors revealed a far-ranging level of awareness amongst targeted groups. Awareness of a solitary consensus conference was very high, varying from 86 to 94 percent in every target groups, with about 7 come 10 percent the the respondents indicating the the consensus statement evoked some changes in clinical exercise (Johnsson, 1988). In a national sample the U.S. Physicians, 41 percent reported general awareness the the program yet only 18 percent claimed they were rather or very familiar v it. Awareness differed by specialty, with oncologists indicating the biggest familiarity and family practitioners the the very least (Kanouse et al., 1987).
Awareness also appears to it is in a duty of physicians" socio-demographic characteristics. Evaluation of the U.S. Data (Kanouse et al., 1987) revealed that doctors who had actually heard the the regime were rather older, had practiced medicine about two year longer, were much less likely to work in private group practice and much more likely to occupational in a hospital, clinic, or various other institutional setting; or were more likely to it is in the members that a clinical school"s to teach staff and to report that they had responsibility for training students, residents, and interns. Moreover, their information habits and preferences were quite different. Physicians who were conscious of the program reported spending more time reading journals such together the journal of the American clinical Association (where many NIH consensus statements room published) and also tended to speak informally with their colleagues about medical topics. They additionally reported spending 30 percent more time attending continuing medical education and learning courses and tended to obtain patient referrals from a larger variety of physicians than did those who were less aware of regimen recommendations.
What is the partnership of conference references to really clinical practice? Three countries report evaluation initiatives to connect conference referrals with actual clinical exercise patterns. The these 3 studies, just the Norwegian results suggest that the consensus conference recommendations affected practice patterns. However, as the review suggests, and as questioned under the section dealing with environmental constraints, this may be much more a function of environmental determinants than the a consensus statement. The researchers provided a preconference, postconference survey style to conference data from the country-wide registration of ultrasound procedures. The analysis revealed a palliation in the average number of diagnostic ultrasound examinations per woman following the promulgation that the agreement conference references on the use of ultrasound in pregnancy.
Data native two remaining studies indicate the contrary. A recent Canadian evaluation of exercise guidelines for use of cesarean sections on the attitudes and also behavior of physicians reveals that there was comprehensive awareness and also agreement on the suggest guidelines and also a self-reported adjust in practice (Lomas et al., 1989). However, the actual analysis of hospital discharge data argued that the agreement guidelines produced small or no readjust in yes, really practice. A similar analysis compare self-reported practice with actual exercise was performed as part of a U.S. Testimonial (Kanouse et al., 1987). Here, changes were measure up in several hospital-based measures that were subject to agreement conference recommendations, providing a comparison between physician self-reported and actual practice vis-à-vis exposure to specific consensus references (Kosecoff et al., 1987). Results verified that the conferences greatly failed come stimulate readjust in physicians" practices, regardless of moderate success in reaching proper target audiences. While this analysis involved physicians and hospitals in just one geographic region of the unified States, and also thus is subject to severe borders of generalization, the data did disclose that physicians" preferred practice trends bear a solid relationship to what they actually do. The link, however, between consensus breakthrough conferences and also actual techniques was quite disappointing. For example, in the analysis of a breast cancer conference, relationships in between physician awareness that the conference and their compliance through the recommendations reflected preexisting differences, no a program effect.
Environmental Constraints and Incentives
The paper definition in which dissemination occurs have the right to facilitate or inhibit the process. The literature on diffusion points to a collection of organizations at the federal, state, and also local levels that impact this procedure (Fineberg, 1985). For example, in Norway, the endorsement by the health and wellness Directorate the the consensus conference explain on ultrasound screening the pregnant women as the nationwide guideline impacted the use of ultrasound screening in clinical exercise (Backe and also Nafstad, 1989). Equally important, however often overlooked, may be subseries the ""supply-side factors"" (Robertson and Gatignon, 1987). Resources of innovative an innovation other than consensus statements may influence physician behavior and are crucial in identify the quantity of persuasive details beingtransfer to potential adopters. For example, the aggressive marketing tactics of personal corporations that produce medical technologies and also the clinical policies of hospitals and clinics that administer care influence physician behavior.
The level to which environmental constraints and incentives affect dissemination or are taken into consideration in formulating a dissemination arrangement varies follow to the framework and function of the program. The an extremely composition that a consensus advancement panel is frequently intended to resolve some of this constraints by including relevant administrators and also policymakers in the consensus advance process. Because that example, the Swedish regimen considers social, organizational, and economic elements of technologies. Thus, the conferences involve specialists in medicine, wellness economics, epidemiology, and health policy, and administrators and also concerned patient groups. The resulting statements go beyond addressing the safety and also efficacy of the technology. The statements room directed towards a much more comprehensive audience, with circulation targeted to came to physicians, politicians, and also administrators.
Evaluation studies have concentrated both top top the awareness that consensus development conferences by health and wellness administrators and also politicians and their awareness of agreement results. Amongst one sample that Swedish wellness administrators and politicians, awareness of agreement conferences to be high (Calltorp, 1988). Eighty-nine percent shown that lock knew about the conference. Ninety-nine percent of the administrators were conscious of the consensus conference, and 85 percent the the political leaders knew about the agreement conference. As soon as queried around their awareness the the outcomes (i.e., the content of the agreement statements), results were same impressive. Eighty-three percent the the respondents were conscious of the outcome of one or an ext conferences. Administrators ranked highest possible (96 percent the the administrators were aware of one or much more statements).
Eighty-four percent that the politicians (full-or part-time) were conscious of one or more of the statements. The latter ranged native a low of 49 percent that were conscious of diagnostic imaging that liver tumors and also 67 percent who shown awareness the the recommendations on sight-improving surgery.
The channels used to find out about brand-new medical technologies have actually been a regular subject of investigation (Eisenberg, 1986; Fineberg, 1985). Consensus advancement conferences have used a variety of channels, offering primary importance to expert journals, both general and specialty, and direct mailings of consensus statements. Table 3 lists the various channels used by countries" program as component of their circulation efforts. Few programs use straight mail or continuing education. The majority of program disseminate various forms of publications to health treatment providers, managers, and policymakers, whereas fewer programs target the general public. The review of details channels has been limited. 2 exceptions encompass the rand Corporation research (Kanouse et al., 1987) the the U.S. Consensus advance program and also the Canadian Research team proposal. The last is a potential series of quasi experiments to evaluate different dissemination tactics (Lomas, 1989). Specifically, the Canadian Research team is conducting a big randomized regulated trial to evaluate two circulation strategies; one strategy uses regional "educational influentials" and the various other strategy involves the use of graph audit and also feedback.
The U.S. Evaluation suggests that consensus recommendations are more likely come reach specialists than generalist physicians (Kanouse et al., 1987). The examine was not able to develop a straight link in between awareness and also publication in a generalist form channel, such together the newspaper of the American clinical Association (JAMA), which publishes most of the NIH consensus statements. The evaluation revealed that reading JAMA had no predictive worth after other factors such as specialty and form of practice were taken right into account. Analysis the brand-new England journal of Medicine and various specialty journals, however, and being part of a well-defined network of clinicians was connected with greater awareness that the consensus advance program. Comparable patterns existed v respect come actual expertise of relevant conferences, with greater levels the awareness being videotaped by doctors reading specialty journals.
The U.S. Evaluation likewise assessed continuing medical education and learning (CME) programs and also direct mailings as alternative communications channels (Kanouse et al., 1987). Dissemination through CME programs was considered an important source in that more than two-thirds of respondent in the physician survey pertained to conferences, meetings, and also CME programs as "very important" details sources both for very first hearing about brand-new medical procedures and for deciding even if it is to usage them. Nearly half of the medical professionals surveyed had learned that the Consensus advance Program through direct mailing of various reports by the nationwide Institutes the Health. A substudy come examine direct mailings to five relevant specialties in the city St. Louis, Missouri, area revealed that significantly an ext physicians who obtained such mailings were aware of the conference and also its recommendations than to be a to compare sample of medical professionals who go not get such direct mailings (Jacoby and Clarke, 1986).
Areas that Future Research
The advance of consensus breakthrough conferences, plenty of with various functions and structures operating within a range of various health care systems, offers an chance for future cooperation research and also evaluation. Sports in function, structure, and setup provide a unique opportunity to set up a series of herbal experiments that can increase the as whole understanding that the straightforward diffusion procedure as well as the effectiveness of alternative dissemination strategies. This expertise is vital for (1) enhancing the performance of consensus advance conferences vis-à-vis their stated goals and objectives and also (2) giving a data basic from which to evaluate the agreement conference approach to dissemination contrasted with other methodologies and programmatic initiatives that can influence doctor practice patterns (e.g., standards and protocol participation). Noted below are several research locations that capitalize top top a systematic and also comparative assessment of consensus development conferences.
Evaluation of certain dissemination methods. The performance of details dissemination tactics is one empirical question and also is arbitrarily on several covariants. One approach would be to collection up a collection of experiment or quasi experiment to evaluate alternate strategies past those traditionally used such as skilled journals and newsletters. For example, the Canadian Research group randomized psychological evaluates 2 implementation strategies: usage of local influentials versus usage of chart audit and feedback (Lomas, 1989). Obviously, this calls for replication in other settings together with the chance to evaluate other circulation strategies such as the usage of "clinical alerts" by pertinent governmental agencies, computerized doctor query systems, and also the usage of follow-up meetings because that selected clinicians that are regarded a certain consensus statement.
Role of business intermediaries. One underlying presumption of most circulation efforts is that the individual physician is the unit of evaluation and need to be the target the the dissemination effort. In reality, however, health care organizations are involved in the delivery and also financing that the modern technology and represent important constituent groups. Thus, castle are crucial actors in the fostering process. This is clearly recognized by numerous of the european programs, in the their panels include administrators and also policymakers, yet also within this context, the clearly target is the physician.
The clearly targeting of organizations and their decision-making procedures requires an expertise of organizational behavior, i beg your pardon is quite different from individual adoption processes. Consideration needs come be given to a selection of components including structure characteristics, the role of coalitions within organizations, and also the idea of secondary choices (i.e., the implementation decision through the organization and also the subsequent adoption decision through the physician).
Interaction the attributes, adopters, and also environmental characteristics. A central issue is the type of diffusion and adoption process that may take place with different varieties of technology, different species of consensus statements, and different environmental conditions. The chance to explore each, and also their interactions, is current in a cross-cultural assessment of dissemination practice. There is a distinctive opportunity to rental a herbal experiment utilizing a collection of tracer technologies for consensus development programs and dissemination initiatives in a selection of countries. This approach would clarification the nature of the interaction between the attributes of the modern technology being diffused, the qualities of the adopting unit and the political and also policy paper definition of various countries. Because that example, one would certainly expect different diffusion patterns in competitive and also regulatory environments. The ability to monitor these diffusion fads over time and to to compare different shipment systems patent insight regarding how larger social factors and also values affect practice patterns (Waitzkin, 1983). This type of review would aid us relocate away native a "unitary technique to diffusion" and also toward building and also testing theory that would have greater relevance to the actual design of circulation strategies.
Dissemination and also changes in actual clinical practice. When evaluations of dissemination strategies have focused primarily on awareness that the consensus advance program and/or specific program recommendations, the real concern is whether dissemination and the resulting awareness actually readjust physician exercise patterns. Couple of evaluations have attempted to assess such changes; and also evaluations that examine the relationships between dissemination efforts, levels of awareness, and also attitudes toward certain conferences with physician habits are needed. This info would provide a an important link come targeting locations of practice requiring consensus recommendations since it is exactly these areas of practice that recognize physician readiness come comply v recommended changes.
Revising assumptions about the duty of dissemination. A good share of our diffusion models, or at the very least the presumptions underlying them, are obtained from a easier time and a easier problem. Clearly, the circulation of details to readjust physician methods is far more complicated than initiatives to adjust the buying habits of the general public. A close check of clinical exercise patterns and decision-making procedures reveals a level of intractability the is not conveniently influenced by relatively simple dissemination practices. For example, a qualitative analysis comparing decision-making methods of medical professionals in the joined Kingdom and also the United says in state of adoption of created versus dynamic (unformed) innovations revealed that medical professional decision-making procedures are significantly shaped through the perspectives of local clinical practices and also are not conveniently influenced by more formal dissemination channels. Ann Greer suggests: "there are no magic signatories or formats which will cause knowledge to jump turn off the page and also into practice" (Greer, 1988).
The intricacy of the decision-making process plainly suggests that factor to consider needs come be given to various other strategies beyond simple dissemination and also that in the future the loved one cost-effectiveness of this strategies should be provided greater attention. This is no to suggest that consensus development conferences and also concomitant circulation strategies be abandoned, but they should be supplemented through private and other public sector initiatives continuous with the underlying process of clinical practice. One approach may be to couple the involvement of clinicians in continuous research (e.g., clinical trials) with the systematic choice of topics because that consensus breakthrough and succeeding diffusion to the practicing community. Because that example, in ~ the unified States, the national Cancer Institute has instituted a ar Clinical Oncology regime that enables local practitioners to get involved in clinical trials research. Combining this kind of involvement v the diffusion of agreement statements may be worthy the consideration. An additional possibility is to capitalize on larger ongoing initiatives to target circulation efforts. For example, in the United claims the share Commission top top Accreditation of medical care Organizations has actually launched a routine to monitor selected organizational and also clinical outcome signs as component of the as whole hospital accreditation process. The availability of this info may aid to target circulation efforts come those clinical areas amenable come and/or request change. Finally, the changing of exercise patterns requires a brand-new recognition the the role of patients and also administrators in the clinical decision-making process. As reflected in many of the european consensus advance conferences, consumer and/or your representatives, in addition to administrators and various policymakers, are essential contributors in the testimonial of given technologies. Customer involvement and influence in changing physician exercise patterns is no well understood and is worthy of investigation and also evaluation.
The consensus advance programs and the resulting agreement statements represent one approach to affecting clinical practice. The development of this approach and its adaptation in both structure and duty under various countries" initiatives provide an essential opportunity to evaluate its utility under a variety of conditions. Evaluations the programs" performance in transforming clinical practice patterns need to take right into account attributes of the technologies considered, as well as the agreement statements themselves and also a selection of organizational and environmental components that affect the dissemination process. The agreement statement have to be recognized as just one affect on clinical practice and should be taken into consideration an integral component of a broader strategy of circulation and an innovation transfer.
Backe, B., and also P. Nafstad. 1989. Advance in exercise of diagnostic ultrasound in Norway after ~ the consensus conference recommending regime screening. Paper presented at the Fifth yearly Meeting of the International society of an innovation Assessment in Healthcare, London.
Downs, G., and L. Mohr. 1976. Theoretical issues in the examine of innovation. Administrative Sciences Quarterly 21(4)(December): 700-714.
Eisenberg, J.M.1986. Doctors" Decisions and the cost of medical Care: The reasons for Doctors" exercise Patterns and also Ways to change Them. Ann Arbor, Mich.: Health administration Press.
Fineberg, H.V.1985. Impacts of clinical evaluation on the diffusion of clinical technology. Pp. 176-207 in Assessing clinical Technologies, academy of Medicine, nationwide Academy that Sciences. Washington, D.C.: national Academy Press.
Kanouse, D.E., R.H. Brook, J.D. Winkler, J. Kosecoff, S.H. Berry, G.M. Carter, J. P. Kahan, L. McKloskey, W.H. Rogers, C.M. Winslow, G.M. Anderson, L. Brodsley, A. Fink, and L. Meredith. 1987. An altering medical exercise through modern technology assessment: an evaluation of the NIH consensus advance program. Santa Monica, Calif.: rand Corporation.
Lomas, J.1989. Profile for the consensus advancement program in Canada. Paper prepared for the academy of medication Workshop on Consensus breakthrough for Medical modern technology Assessment, London.
Lomas, J., M.W. Enkin, G.M. Anderson, K. Domnick-Pierre, E. Vayda, and W. Hannah. 1989. The duty of consensus statements in an altering physician"s awareness and attitudes, knowledge and behavior. Paper presented at the Fifth annual Meeting the the International society of modern technology Assessment and also Healthcare, London.
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Robertson, T., and also H. Gatignon. 1987. The diffusion the high technology innovations: A marketing perspective. In brand-new Technology as business Innovation: The advancement and Diffusion the Microelectronics, J. Pennings, editor; and A. Buitendam, editor. , eds. Brand-new York: Ballinger.