When Is a Consensus Paper Not a Consensus Paper?

 

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You may have noticed more consensus papers recently published by this journal and others. In general, the purpose of these papers in medicine is to provide a best evidence-based, not opinion-based, statement reflecting the collective agreement of experts on a specific medical topic; the eventual goal is to guide clinical practice. Some larger topics recently taken on by this journal include the role of debridement and approaches to husbanding antibiotic use. Other journals have spent a fair amount of time and space on pieces about product pricing and guidelines for such pricing. Others have used consensus methodology to change nomenclature. Usually, however, the topics in medical journals are therapeutics without strong evidence or broader topics for which definitive evidence is lacking. Consensus development is most often needed when data are insufficient or contradictory, relying on structured expert interpretation. At the core of the consensus process is identifying a central tendency within the group and grading the level of agreement reached.

The most common methods used for consensus in the health field are the Delphi method, nominal group technique, RAND/UCLA Appropriateness Method, and National Institutes of Health (NIH) Consensus Development Conference. Consensus does not need to be defined as full agreement among participants, but simply excluding dissenting opinions is not consensus. Valid methods may include a vote determining the percentage of agreement (eg, 80%) among participants, use of a rating scale in which a specified mean rating must be achieved on each topic for inclusion by the group, or a requirement that a majority of participants give a topic a certain rating for that topic to be included.

There are many items the reader must look for when reading a consensus document. The first is the makeup of the expert panel and why its members are experts. The composition of the group is important in determining the decision reached. Usually, increased diversity in the background and geography of the group increases the applicability of the group’s findings. Although a larger group increases the reliability of the eventual output, if the group is too large it can become difficult to manage. Reliability of consensus recommendations declines rapidly when the group size falls below 6, and above 12 improvement in reliability is not substantial.1 One item the authors must report is whether anyone who was invited as an expert was excluded from the final report; if this occurs, the authors are submitting an opinion piece, not a consensus document.

The second thing to look for is the methodology. In all settings, the question or questions to be answered must be defined, and in most cases a literature search should be undertaken to provide a basis for the conversation. The Delphi method attempts to provide consensus by asking well-defined questions based on surveys and feedback. Usually, this method is applied when consensus among large numbers of participants is needed. The method is marked by 3 rounds of refinement of the questions asked, followed by analysis and reporting. The nominal group technique is a face-to-face structured group meeting of experts led by an experienced moderator, in which a question is generated for which an expert panel is convened. This method uses the independent generation of ideas and the round-robin listing of these ideas, followed by a discussion led by a moderator. This method is used to establish a prioritization of outcomes. The above 2 methods are those most often used in the wound care environment.

The RAND/UCLA Appropriateness Method employs 2 independent groups: a core panel and an expert panel. The core panel synthesizes the current literature to provide to the expert panel. The expert panel then uses those data to come to a consensus. This method is often used to evaluate the appropriateness of specific therapies. There are usually 2 rounds of Likert scale determination in the RAND/UCLA Appropriateness Method. Of note, because of its strong reliance on a synthesis of the literature, this may be a more ideal way to develop clinical practice guidelines when evidence is insufficient.

At the national level, there is the Consensus Development Conference. This is a formal system that brings together selected experts in the field and concerned individuals, from experts to the public, to reach general agreement about the safety, efficacy, and appropriateness of using various medical therapies. The Office of Medical Applications of Research of the NIH is responsible for the work product of this group.

In short, I hope the reader enjoys and respects the effort and time that go into developing consensus documents. However, I also hope they read the documents with a critical eye. The author or authors need to state the purpose of the document, explain the qualifications of the expert panel, and outline the methodology and timeline of the process. In closing, there must be adjudication of dissenting opinion in a true consensus panel, which can lead to less definitive direction for the reader.